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List of figures VIII
List of charts and tables X
Glossary: explanation of terms and abbreviations XII
Statement of authorship XV
Curriculum Vitae, Tom Guthknecht XVI
PART A: OVERVIEW 1
1 INTEGRAL PROCESS DESIGN [IPD]: STUDY BACKGROUND AND SUMMARY 1
BACKGROUND: Improved Planning and Operations for Complex Buildings 1
SUMMARY: Integral Process Design [IPD] 2
2 INTEGRAL PROCESS DESIGN [IPD] FOR COMPLEX BUILDINGS 3
2.1 Mission statement 3
2.2 Problems of complex procedures : The airline example 4
2.3 Problems of complex procedures : The operating room (OR) example 6
2.3.1 What are the problems of complex structures in health care? 6
2.3.2 Conditions in the operating room 6
2.3.3 Assumption traps in the operating room 7
2.3.4 Management problems in the operating room 7
2.4 Integral Process Design response : The Berne OR-Cluster 8
2.4.1 Concept 8
2.4.2 Impact of the Berne OR Cluster 9
2.4.3 Outlook for Integral Process Design 9
2.5 Cost-free hospital investment: Eight statements for a new approach 10
2.6 SENIC study: successful implementation of study findings 11
2.7 From SENIC to IPD: quality improvements and cost reduction 11
2.7.1 How to approach the non-tangible: effective incentives for health care planning 11
2.7.2 Structure of Planning for complex buildings today 12
2.7.3 Goals of IPD : Embedding incentives in today’s structure 13
2.7.4 Today’s Paradigms in the planning of complex buildings 14
2.7.5 Today’s Lack in Strategic Options 15
2.8 Situation analysis summary of health facilities today 15
2.8.1 Performance problems in the running of health facilities 15
2.8.2 Sweet dreams of efficiency 16
2.8.3 The Assumption Trap in health facilities 17
2.8.4 Financial context summary of health facilities 17
2.8.5 Demotivating health care remuneration structures 17
2.8.6 Escaping the downward spiral: Introduction of small scale incentives 18
2.9 Challenges 19
2.9.1 Challenges in health care 19
2.9.2 Challenges in health facility operations 19
2.9.3 Challenges in planning 20
2.9.4 Challenges in implementation 20
2.9.5 From user talks to Transition Assistance 20
2.10 Complex building business case positioning 21
2.10.1 “Hospitals are accidents! They should not happen!” 21
2.10.2 “Hospitals are far too valuable to care only for ill people!” 21
2.11 INTEGRAL PROCESS DESIGN [IPD] : The concept 22
2.11.1 Function of IPD in the planning process 22
2.11.2 Structure and Components of IPD 22
2.11.3 Interface of IPD with the DRG medical service remuneration concept 23
2.11.4 Reversing the focus: From maximum use of space to maximum use of personnel 24
2.11.5 Unique Selling Points of IPD 24
2.11.6 The Market: Customers of IPD 25
2.11.7 Added Value 25
2.11.8 Implementation 26
2.11.9 Implementation of the IPD concept on a larger scale 27
Notes related to PART A : OVERVIEW 28
PART B: CONSTRAINTS 33
3 HEALTH FACILITY STRUCTURES : SHORTCOMINGS AND LIMITATIONS 33
3.1 The “time frame” problem of today’s health facilities 33
3.2 Lack of transparency during the planning of complex buildings 33
3.3 The mistakes of the “tailor-fit” solutions in today’s planning 34
3.4 Consequences of rigid focused plans: Lost flexibility 34
3.5 Reduced space occupancy and permanent service provision 34
3.6 Analysis: the limitations of today’s planning processes 35
3.7 Why do today’s health facilities seem to be outdated faster? 36
3.8 Strategic Space in hospitals 36
4 IMPACT OF HEALTH SERVICES FINANCING AND REMUNERATION 37
4.1 From Patient Classification Systems to Diagnostic Related Groups 37
4.2 ‘Fee-for-service’ remuneration : a major obstacle for efficacy 38
4.3 Separated budgets: a key problem for efficient planning 39
4.4 Hospital capital investment 40
4.4.1 Could hospital building investment be free of charge? 41
4.5 Current remuneration systems: “Disincentives” for doctors 41
4.6 Consolidation of separated investment and operational budgets 42
4.6.1 Monistic’ a model of unified health facility financing? 42
4.6.2 The Swiss TARMED catalogue and the German health fund. 43
4.6.3 The Dutch model of advanced DRG management. 44
188.8.131.52 From DRG to DTC: Combined hospital and external costs coverage 44
184.108.40.206 Yardstick competition: gradual adaptation towards higher efficiency 45
220.127.116.11 Consequences for the planning of health facilities 45
5 HEALTH FACILITY OPERATIONS : PROBLEMS TO ADDRESS 46
5.1 Assumption Trap: Working environment 46
5.2 Assumption Trap: Managerial structures 47
5.2.1 Potential and limitations of outsourcing: example maintenance 47
5.2.2 Outsourcing risks 47
5.2.3 Internal outsourcing: a win-win situation 48
5.3 Pitfalls within organizational concepts 48
5.4 Inherent inefficiency due to permanent service provision 48
Notes related to PART B : CONSTRAINTS 49
PART C: CONCEPT 55
6 CONCEPTS FOR THE PERFORMANCE MANAGEMENT IN HOSPITALS 55
6.1 Clinical Path Management [CPM] 55
6.1.1 Organizational improvements with Clincal Path Management 55
6.1.2 Lean Process Management in hospitals [LPM] 56
6.1.3 Pilot-study: Lean management at the
University Center of Cardiology, Freiburg 57
6.1.4 Clinical Path Management: Conclusions 58
6.2 The OPIK project 59
6.2.1 Origin and background 59
6.2.2 Concept and goals of the OPIK model 59
6.2.3 The OPIK model: Conclusions 59
6.3 Evidence Based Design [EBD] 60
6.3.1 Origin and background 60
6.3.2 Concept and goals of Evidence Based Design 60
6.3.3 Applied tools of Evidence Based Design 60
6.3.4 Working with virtual patients to focus on the real needs 61
6.3.5 EBD focus: Improving the conditions for a healing process 62
6.3.6 Balancing one-time investment costs and operational costs with EBD 62
6.3.7 Evidence Based Design: Conclusions 62
6.4 The CORE-Hospital concept 63
6.4.1 Origin and concept 63
6.4.2 Goals and benefits of the CORE Hospital concept 63
6.4.3 The CORE Hospital concept: Conclusions 66
6.5 Outlook: A synthesis with Integral Process Design 66
7 IPD : AN APPLIED STRUCTURE FOR INNOVATIVE PLANNING IMPLEMENTATION AND EVALUATION 67
7.1 Approach and limitations in the case-oriented evaluation of this study 67
7.2 Embrace Plan 67
7.2.1 Today’s strategic limitations of the planning tools 67
7.2.2 Situation: master plans do not integrate business modeling 68
7.2.3 Benefits and shortcomings of today’s strategic planning tools 68
7.2.4 Definition and consideration of business criteria 68
7.2.5 Recent trends regarding the provision of basic planning information 68
7.2.6 Additional requirements for strategic planning 69
7.2.7 The integral hospital business plan: A ‘White spot’ in planning 69
7.2.8 Effective planning: Early detection, early response 69
7.2.9 Elements of an Embrace-Plan 70
7.3 Operational Flow Planning 71
7.3.1 Overcoming the provision gap: integrating unused resources 71
18.104.22.168 Making use of off-peak staff availability in accident & emergency 71
22.214.171.124 Coping with the provision gap at accident and emergency departments 72
126.96.36.199 Combining maternity and early rehabilitation 72
188.8.131.52 Provision gap and trends for patients’ length of stay 73
7.4 Healistic design: Quality and healing 74
7.4.1 Defintion of Healistic Design 74
7.4.2 Noise control and fear management with Healistic Design 74
7.4.3 Case in point noise control: Patients’ specific noise separation 74
7.4.4 Visual control with Healistic Design 74
7.4.5 Case in point visual control: Specific view control for patients 74
7.5 Grey Performance Analysis 75
7.5.1 Challenges: staff works hard but still is not efficient 75
7.5.2 Benefits: increased efficiency with Grey Performance Analysis 75
7.5.3 Approach: Structure of Grey Performance Analysis 75
7.5.4 Trend assessment of the cost saving potential with GPA 78
7.5.5 Grey Performance analysis: Operating department AOH-08 79
7.5.6 Return on Design assessment: Operating department AOH-08 81
7.6 Definition of Joker Areas 85
7.6.1 Joker Areas: Selection criteria for interfering with a complex system 85
7.6.2 Joker Areas: Economic and performance criteria 85
7.7 Business Modeling 88
7.7.1 IPD: Application of Business Modeling 88
7.8 Strategic Space Design 90
7.8.1 The lack of strategic spaces in today’s health facilities 90
7.8.2 The potential of strategic spaces in health facilities 90
7.8.3 Strategic Space Design: STEP 1 management of physical spaces 90
7.8.4 Strategic Space Design: STEP 2 management of healistic resources 91
7.8.5 Strategic Space Design: STEP 3 allocation management 91
7.8.6 Harmonizing the Anesthesia workflow 92
7.8.7 Transparency of wards versus longer ways (the Paris example) 93
7.9 Integration of additional business: The Joint Business Case 95
7.9.1 Hospital Care today: A monoculture business environment 95
7.9.2 Hospitals managed like airports: “And if your hospital was managed by Schiphol airport!” 95
7.9.3 Planning for complex buildings and the Joint Business Case 95
7.9.4 The Joint Business Case: An Economic Solidarity Model 96
7.9.5 The Joint Business Case: A Model for the Dongtan Eco Life City 96
7.9.6 The Joint Business Case: Elements and concept 97
7.9.7 The Joint Business Case: A model for Otto Wagner Hospital 98
7.10 Transition Assistance 102
7.10.1 Transition workshops and staff empowerment 102
7.10.2 The Klagenfurt resource model 102
7.10.3 Beating the assumption trap with continuous education 102
Notes related to PART C : CONCEPT 103
PART D: IMPLEMENTATION 109
8 IPD : RETURN ON DESIGN 109
8.1 Benchmark criteria: Economic design validation with IPD 109
8.2 Scenario Planning with IPD 109
8.3 IPD: An instrument to manage the DRG transition 110
8.4 IPD: Economic and performance impacts of implemented IPD 111
8.5 IPD: Economic effects of an implemented Joint Business Case 112
8.5.1 Approach 112
8.5.2 Investment requirement 112
8.5.3 Consequences of the variants for the market position of [AOH-02] 113
8.6 Economic validation of health facility projects with IPD 114
9 IPD : MODERATING BUSINESS AND ARCHITECTURE 115
9.1 Challenges to design an efficient hospital. 115
9.2 From libertarian paternalism to over-regulation 115
9.2.1 Libertarian paternalism and the paradigm of free choice 115
9.2.2 Medical quality assurance and the trend for over-regulation 115
9.2.3 Visualizing process and design coherence 116
9.3 Creating a ‘choice architecture’ 116
9.3.1 From guidelines to a choice architecture 116
9.3.2 Nudges for more efficient health facilities’ 116
9.3.3 Design challenge: combining primary and secondary service excellence 116
9.3.4 Designing a loose-fit default concept 116
9.4 Default typology considerations 117
9.4.1 Modular building typologies 117
9.4.2 Allowing change with modular building elements in care 117
9.4.3 The ‘Vertical Embracement’ principle 117
9.4.4 The ‘Sandwich’ typology 118
9.4.5 Default ‘Sandwich’ layout recommendations 119
9.4.6 The ‘Slice’ concept 120
9.4.7 Clustering for optimal use of human resources 120
9.5 Default structural considerations GDHS (Grid / Depth / Height / Shape) 121
9.5.1 GDHS, [G]: The building grid 121
9.5.2 GDHS, [D]: The building depth 122
9.5.3 GDHS, [H]: The building height 122
9.5.4 GDHS, [S]: The building shape 122
9.6 Default organizational considerations 123
9.6.1 Design coherence: ‘Definitions to allow adaptability’ 123
9.6.2 Team coherence: a challenge during long term projects 123
9.6.3 Decision coherence: ‘The golden rules’ 123
9.7 The Moderation challenge 124
9.7.1 Achieving coherence within complexity: who is not at the table? 124
9.7.2 IPD early stage moderation for better use of human resources 125
9.8 Potential for further research 126
10 IPD : CONCLUSIONS AND OUTLOOK 127
10.1 Goals, characteristics and benefits of IPD 127
10.1.1 Integral Process Design: A toolbox for higher efficiency in complex
10.1.2 Cost-neutral hospital investment: A real perspective or just a dream?128
10.1.3 Cost-neutral hospital maintenance and refurbishment 128
10.1.4 Strategies to avoid the misdirection of IPD cost savings 128
10.1.5 Design coherence: A key factor for the success of IPD 128
10.2 Market for IPD: Clients and Added Value 129
10.3 Implementation strategies for IPD 129
10.4 IPD proposals for the design of complex buildings 129
10.5 Integral Process Design: Conclusions and outlook 130
Notes related to PART D : IMPLEMENTATION 131
11 APPENDICES 132
11.1 Bibliography 132
11.2 Internet sources 142
12 INDEXES 144
12.1 Index of terms 144
In this study the concept of Integral Process Design is discussed and explained. The idea of Integral Process Design is to provide a ‘bridge’ between business outline and building concept at the earliest possible moment. This allows assessing the long term building qualities with an early focus on business functionality.
Scope and scale of the study:
The scope of this study is to increase the efficiency of complex building structures using health facilities as an example by improving the interdepartmental interfaces of hospital departments. The scale of this study is to compare data derived from projects with implemented IPD to the efficiency status of state-of-the-art health facilities without IPD efforts.
Goals of this study:
This study aims to facilitate an improved conceptualization of complex buildings using health facility planning as an example. In parallel to construction planning, instruments for early business modeling are introduced to prepare the ground for appropriate architectural responses to functional and business needs.
Integral Process Design is a summary of the research and project efforts during the past two decades with an attempt to increase business coherence.
Business modeling and new planning instruments are explained by projects where these instruments were implemented.
Methodology / Evaluation Approach:
In the study the following methodology is applied:
Analysis of the existing situation(s), pointing out neglected elements in the planning and management process; visualization of the consequences.
Definition of Integral Process Design [IPD]
Proposal for a restructuring of the planning / design process in order to enable ongoing cost control not just for running costs from day one of planning.
Visualization and evaluation of the IPD potential for cost savings and benefits.
Appropriate architectural typology responses which enable higher efficiency.
Suggestions of IPD implementation in health facility projects, next steps.
Due to the case-oriented approach, some of the detailed results and suggestions might not be directly applicable in a general way without adaptations.
In order to protect the rights of individual hospitals and stakeholders in health services, some hospital names are made anonymous (e.g. Hospital “x” = AOH 01, etc.).
Data anonymity is applied wherever considered necessary to protect the information rights of the data providing institutions.
Author: Dr. Ing. T. Guthknecht
Health care systems throughout the world face financial collapse. Costs must be reduced. The focus of this study is to show reduction potential of hospital cost which account for ca.25-30% of health care budgets in many OECD countries. (CDC, 2009)
Goal of IPD: Cost-free hospital investment and maintenance:
The goal of Integral Process Design is to liberate sufficient resources so that the entire construction and refurbishment budget for hospitals could be free of charge.
Efficiency problems and challenges in hospitals:
After the efforts of process optimization in hospitals in recent years, the next big opportunity lies in tracing and avoiding interdepartmental inefficiencies in hospitals.
Invalid planning information: the Assumption Trap:
Today’s planning information is based on optimal positive assumptions which are not a coherent reality in hospitals. Planning has to be more realistic and avoid dangerous ‘Assumption Traps’ which lead to misdirected investments.
Today’s paradigms of complex building planning, example: health facilities:
The planning of complex buildings -such as health facilities- is in many ways a reactive process. Prospective cost control and sustainable planning strategies can not be applied sufficiently.
Constraints for effective planning in today’s health care structures:
Effective planning today is impeded by the remuneration structures of medical services and the general lack of economic incentives in hospitals.
Concepts for the performance management in hospitals:
Various valuable performance management concepts have been developed recently. Interdepartmental inefficiencies however did not get sufficient attention.
Concept of Integral Process Design:
The concept of IPD is to select certain focus areas (Joker Areas) with high yield potential of cost reduction and low negative collateral impact. With the optimization of the workflow between these Joker Areas, costs are significantly reduced.
Externally imposed inefficiencies: Grey Performance in departmental interfaces:
IPD focus on externally imposed inefficiencies: targeting ‘Grey Performance’.
Architectural consequences of IPD:
IPD significantly influences the organizational structure, functional layout and architectural planning of complex buildings. Health facility architecture must change its focus from optimal use of surfaces to optimal use of human resources.
Striving for a new Economic Solidarity Model with additional revenues:
More revenues are possible by surrounding building design with business design.
Assumption traps of IPD: limitations of this study:
The positive results of IPD cost reductions could be abused for other urgent hospital budget positions or lost in the negotiations with state or insurances. A moderating board function needs to safeguard the correct allocation of IPD-generated revenue.
Despite challenges and limitations: Free hospital investment is possible with IPD.
Situation of health care:
Health care today is characterized by the following factors in OECD countries:
The health service in many countries faces serious finance challenges [ 1 ].
Health care is fast growing and is one of the biggest sectors of employment [ 2 ].
It depends on social budgets and insurance contributions for financing. [ 3 ].
Health care costs are growing faster than the Gross National Product (GDP) [ 4 ].
This results in a serious financing deficit of health care and hospital provisions [ 5 ].
The coming decades are defined for health care by these key points:
Demographic shift in an ageing society causing an increase in multi-morbidity [ 6 ].
Mass-misbehavior causes epidemiological challenges: the obesity/diabetes wave [ 7 ].
Change of focus:
Today acute care in hospitals focuses to a large extent on re-active ‘repair-care’. In ageing societies ailing from pandemic so-called “diseases of civilization” (obesity / diabetes / smoking / alcohol abuse) the focus must be changed to pro-active prevention and self responsible health maintenance. The planning process must also change to support preventative health. The moderation of functional needs and optimization of interdepartmental cooperation is a prerequisite for successful planning and operation. This integral planning process is called in this study Integral Process Design.
Use of resources:
Hospital care uses 30% or more of the entire health care budget in many OECD countries[ 8 ]. Improved performance efficiency in this sector can therefore have significant influence on the entire economic performance of a health care system[ 9 ].
The complex structures of hospitals are financially in a critical condition:
Hospitals today can be considered like patients in critical condition. Their procedures are “obese and life-threatening” to the hospital business. Insufficient incentives are provided to support the “economic fitness” of hospitals.
The missing point:
Health services and their complex building structures are in critical condition. Swift and concise efficiency improvements must be achieved. Like in emergency care a triage process approach is required to prevent the health service from economic infarction.
Interfering with complex systems is a risky task. Often interventions for improvements create new additional problems which even aggravate the initial situation. The challenge is to turn performance improvements within hospitals into tangible revenue increase while minimizing collateral negative impacts. Besides being a promising concept, the strategy to implement the suggested changes in the health service on different scales is going to be the biggest challenge.
Contribution of architecture and planning:
Today there are insufficient planning instruments to support the optimized use of human resources in complex buildings. By focusing on certain high yield areas with low collateral negative impact (‘Joker Areas’) better performance efficiency can be achieved. Integral Process Design can contribute to these necessary improvements.
Have you ever experienced having to wait exceptionally long for a meal on a long distance flight? It is exhausting to fly long hours, hence it is nice to fly for example a famous renowned Asian airline. The ambience is great and the cost performance ratio in economy class is good.
But if you take e.g. a flight around 12:30 from Frankfurt to Asia in order to arrive early morning next day and you happen to sit in the aircraft in row ten or further down from the kitchen block, you had better go to sleep right away or take with you a sandwich and some drink. This is because on average it will take 1½ to 2 hours after take-off before you will receive your meal in the plane. And this is not on a one-time experience, it is a pattern!
What are the underlying process management problems?
When you finally receive your lunch the exhaustion is written in the faces of the friendly personnel and it is quite obvious what went wrong in process management:
Special meals (on request prior to flight) are served first and cause enormous delays because individual time consuming processes which serve only few customers are preceding standardized efficient processes which serve many.
When the first meal trolley leaves the kitchen block, it serves to about row 6. Then there comes the surprise: The empty trolley is unfortunately not pulled back to the kitchen and replaced with a new full one. Instead several steward(s)esses try to refill the void trolley from the back with individually reheated meal trays while on the other side the serving steward(s)esses wait impatiently for the right sequence of trays to appear. The meal trays are not even handed over directly but pushed into the trolley and immediately pulled out on the other side like an involuntary Pavlov reflex reaction.
To make things even worse the distribution of meals is combined with the serving of drinks. This causes further delays: while for the meals in economy class there is usually a choice of 2-3 meals, the choice of drinks for the meal leads to another timeconsuming decision making process for each customer.
What could be done?
More time is lost and the passengers from row ten onwards are looking desperately at the meal-trolley-traffic-congestion matching their every morning rush-hour frustration.
Having seen this problem a few times on various flights I wondered whether I understood the full picture. So I asked my friend Stephan Wirtz who teaches hospitality experience marketing and is a real flight expert, as he seems to be more in airplanes than on the ground. His experience from the many flights he had with the same airline regarding efficient management of in-flight processes coincided with my personal findings. Several times he spoke to the purser who overseas flight attendants and passenger comfort during the flight and he even wrote a report to the airline which suggested the following managerial remedies:
Meal services should start with standard meals (including a sealed cup of water on the tray) to keep decision quantity down and maximize speed on a process which will have a benefit for a maximum of passengers.
Following that, dedicated personnel should serve the specially requested dishes.
The drinks trolley should follow, taking down the pressure of joint serving and leaving enough time for passengers to choose. As a result, meals could be provided much faster. A disadvantage would be the late serving of special drinks to the back rows, but you have to pay a price somewhere. These suggestions were made to steward(s)esses during flights and directly to the airline but there was never any response. Instead, the airline –which has been voted one of the best– meticulously makes reports when there is too much salt in the salad dressing or the cake is too juicy while the customer experience for more than half of the passengers is impaired and resources are wasted unnecessarily with tray-balancing steward(s)esses. It is interesting how Stephan Wirtz’ findings on operational details differ from the general evaluation of his namesake Jochen Wirtz who describes the undisputed general success of this airline. (Wirtz, 2005).
The same differing assessment between global and detailed results can be found in the planning and running of complex buildings and in particular in the health service.
A frustrating summary
The example is not limited to travelling with an airline. It shows how persistent performance failures can exist in complex working environments especially if they are combined with time pressure. The worrying résumé of the quite straightforward meal serving workflow sequence is:
There is an inappropriate sequence of individualized and global-general processes.
The general process of distribution is mixed with the individual logistic process of refilling the trolley.
Processes with multi-parameter decisions (choice of drinks) take precedence over few parameter decision processes (choice of food).
Customer focus is lost as it is assumed that all customers can be served well but only the first few rows will get a good service. This is what I call the “assumption trap”.
Decision hierarchies impede improvements as steward(s)esses admitted that they would like to change the workflow accordingly but are not allowed to do so as such a decision would have to be made by company headquarter policy makers.
Compared to the airline example things are much worse in health care:
Hospital processes are often unclear and are not transparent to clients/patients.
Professional hierarchies in hospitals often protect more the power structures than patient rights and needs.
The workflow sequences in hospitals have many more influencing parameters which increases the risk of an “assumption trap” by making wrong conclusions.
The economic success of individual departments is constrained by the performance of other medical, logistic or administrative functions.
Good performance is impaired by externally imposed inefficiencies. Within the IPD concept this type of inefficiency is called ‘Grey Performance’.
While efficiency in the airline business is driven by tough competition and narrow profit margins, hospital care shows a perturbing lack of efficiency and incentives.
In many countries hospitals are today even punished for efficiency like: “Lower your running cost and we will cut your annual budget.”
As a result, billions are wasted unnecessarily in hospital care.
What can be done for other complex environments and how can architecture contribute?
Innovative planning instruments for complex buildings must make visible processes and operational interdepartmental interfaces.
A thorough business scenario modeling is a prerequisite and an indispensible foundation for good health architecture.
Health facility architecture must translate operational interface management into an adaptable building envelope which corresponds to the changing needs of health service provisions in a hospital.
This study aims to make propositions for improved planning and operations for complex buildings using the health care sector as an example.
In operating rooms working sequences are a lot more complex compared to the distribution of food in an airplane.
Processes are much more individual compared to the airline example.
Conditions of each individual patient (client) have to be monitored meticulously.
The entire workflow is guided by the paradigm of patient wellbeing as many of the activities can have harmful or even life-threatening effects for patients.
The predictability of the planned workflow in the OR is limited: The workflow may be altered due to critical changes of the patient’s condition or due to the experience of the surgical team [ 10 ].
The sequence of work can be interrupted by new non-programmed emergency cases which supersede the flow of the elective program of operations.
Working in an operating department requires all participants to cope with a dynamic and complex environment where the stakeholders cannot contemplate alternative solutions due to lack of time.
The various specialist groups in an OR often set their priorities differently and the working environment is characterized by strong decision hierarchies. These power structures do not necessarily reflect the best and efficient operational solution.
Time pressure and contradictory critical paths increase the likelihood of misunderstandings and questionable decisions with regard to performance and quality.
The planning of the operating department can be particularly blurred by assumption traps. During the planning and realization of operating departments misguided situation assessments often lead to incorrect evaluation of the condition of the functional environment.
The following list shows a few of these illusionary and faulty assumptions:
All staff in the operating department are motivated and alert to avoid mistakes(?).
Work procedures and the working environment (planned spaces and functions) allow equally for standard work performance and performance during stress periods (accumulation of work, emergencies, night shift etc.).(?)
Staff and planners are aware of best practice methods to avoid hygiene mistakes.(?)
Work sequences are managed in a way that they do not collide or contradict their mutual intentions.(?)
Spaces are planned and work sequences are organized in a way which guarantees an optimal use of the most precious resource in a hospital: the medical and nursing staff.(?)
The optimal workflow in an operating department depends to a large extent on external factors. The correct timing of external services such the arrival of patients, supplies, surgical teams, transport services and waste management is a crucial success factor for the operating department. As a result, recent developments in hospital resource ITsolutions reflect the need to connect resource management of intensive care, operating department and surgical wards. Management problems in the operating department occur in particular when the interfaces of the various activities cannot be harmonized adequately. During his own working experience in the operating department of the Occupational Accident and Trauma Centre, Tübingen, Germany, the author experienced that the optimization of few management parameters (cleaning of OR, timely presence of patient, allowance of instrument setting, precise presence of surgical team) can make a difference of 1.5 hours in a 6 hour surgery program in one OR. Hence good resource management results in a time efficiency increase of 25%.
[Graphics and tables are omitted from this preview]
Figure 1: Colliding work sequences in the OR preparation (TG) [ 11 ]
The operational concept in operating rooms has favored the concentration of too many activities in the operating room for a long time. The area with one of the highest investment in the hospital should focus on revenue yielding activities only. All activities which do not directly belong to the surgical operation should be kept out of the operating room as best as possible.
[Graphics and tables are omitted from this prewview]
Figure 2: The challenge: Hygiene performance [ 12 ]
In the competition for the new functional building for the University Hospital Berne in 1998, 24 operating rooms (ORs) were requested as defined in the program of requirements to be 24 for the competition. However the need for operating time capacity was larger than the equivalent of 24 operating rooms.
The challenge was how to increase the operating room output capacity without increasing the surface of the operating department. The author developed for this competition the Berne-OR-Cluster-model: instead of providing even more operating rooms, the functional layout of the rooms should allow a 20% increase in performance. (Guthknecht, 1999/09c,3).
The key challenge in operating departments is the management of various interacting complex systems with the joint paradigm of patient wellbeing[ 13 ]. The Berne OR-Cluster keeps out nonsurgical activities out of the operating room. The instruments for the following operation are laid out in specially assigned spaces connected to the sterile instrument corridor. Specialized anesthesia which takes longer to prepare (such as supraclavicular plexus and lumbar anesthesia) is performed in specially assigned anterooms. This way, the optimal workflow is not impeded. A combined recovery and holding area enables the OR-managing staff to bring the patient to the OR with perfect timing. By providing a departmental interface area (patient holding) at the entry to the OR, the department’s performance no longer depends upon the performance of other departments [ 14 ].
Integral Process Design
With the Berne OR-cluster all preparation activities are kept out of the operating room. Instrument preparation, anesthesia preparations are kept completely out of the OR. The concept of the Berne OR-Cluster represents in this way a core idea of Integral Process Design: structured and focused activities combined with optimal interfaces with other departments.
Outcome and results
[Graphics and tables are omitted from this prewview]
Figure 3: Berne OR-Cluster: layout (TG)
The introduction of the Berne OR-cluster concept allows for an approx. 20% increase in performance with moderate additional investments in anterooms (anesthesia) and preparation rooms (instrument layout) [ 15 ]
Today, more than 10 years after the publication (Guthknecht, 1999/09c) the Berne ORCluster has been adopted in many hospitals (e.g. University Hospital Hamburg Eppendorf) and is considered to be a contribution towards functional process design and an improved performance of the operating departments, as Ludes showed in the comparison of conventional OR structures and the Berne Cluster (Ludes, 2006). Nickl-Weller wrote: “The discussion about the cluster concept was controversial at first but as it appears now it (the cluster concept) represents a significant milestone for the innovative OR. (Nickl-Weller, 2005, p.18, 30). [ 16 ]
[Graphics and tables are omitted from this prewview]
Figure 4: Berne OR-Cluster: detailed concept (TG)
The Berne OR-Cluster is an example of how departmental workflow optimization (ORCluster) has to be combined with improved external interfaces (combined holding / recovery) in order to turn the improved time efficiency into tangible revenue. The ORCluster is a case-in-point how process design can contribute to an improved performance on a global and detailed level. It seems that there is a lack of coordination both on the planning level as well as on managerial level in many hospital departments. The challenge is to repeat the achievements of the Berne-OR Cluster for as many other hospital departments as possible.
 The situation is appalling: Studies showed early 2008 that one third of Germany’s 2’200 large hospitals (~750 !) face bankruptcy despite working at the limits of their capacity. And hospital care in many other countries faces the same problem: hospital care is in deficit. In Germany for example out of an annual running budget for hospitals of around 66.1 billion Euro, around 2.8 billion or about 5% of the annual running cost is used for refurbishment and new hospital construction. This study will show that Integral Process Design carries a cost reduction potential of about 8% - 10% of the annual running cost. Hence all hospital capital investment could be free of charge![ 17 ] (Rürup et al. 2008, p.5)
 On the other hand, system-caused inefficiencies in hospitals result in avoidable losses of billions of Euros each year, as hospital departments are not interfaced sufficiently. (Guthknecht, 1999/09c). Process improvements today often focus on detailed workflows only, and can not be conveyed into tangible revenues.
 Planning conditions for health facilities are becoming more difficult as planning information such as functional specifications, performance specifications, space requirements, strategic planning, organizational concepts are often insufficient or fragmentary. Hence the basic information before planning is often questionable at the high risk for ill-guided investment. (Guthknecht, 2002/09b).
 Hospital care uses 30% to 40% (Allianz, 2005) of the health insurance compensation budget in many OECD countries. Unnecessary losses due to inefficiencies cannot be accepted any longer. (Wright 2009)
 The misconception of investment costs and operating costs of health facilities leads to the lack of sustainable hospital investment. In hospitals, operating cost outweighs investment cost in 2½ years or less. This means that in a hospital with construction cost of 300 million €, about 150 million € or more are spent each year on operating costs. If 8% of the operating costs (12 mill.€ p.a.) could be saved, the hospital in ten years would get an entire refurbishment and extension budget of 120 million € for free! This study aims to show that an 8%-10% operating costs reduction is achievable by applying new management and planning concepts.
 In an ageing world threatened also by a global pandemic of obesity[ 18 ] and in its wake Diabetes type-2 [ 19 ], health care cost must be reduced in general. In 15 years, the cost of obesity and diabetes could take 30% of the total budget for health care. Planning and construction of health facilities must actively contribute to lower operating costs of the facilities by fostering preventive behavior and public alertness.
 The cost reduction with an Integral Process design approach may however not lead to the usual reduction in staff capacity. In preparation for the coming decades of ageing and multimorbidity cost must therefore be reduced significantly while maintaining the level of staff in health care to stem the tidal wave of increasing need of care.
 The goal of reducing cost and maintaining staff level can be achieved by surrounding the hospitals with new revenue yielding activities (Joint Business Case) in the field of disease prevention, health maintenance and wellbeing. Experienced medical staff can be hired out from the hospital on an hourly base for wellness and prevention activities.
[ 1 ] (section 2.1 page 3) Economic problems of health services today: “Health care systems across theEuropean Union face a common challenge: the high cost of health care. Governmentsstrive to ensure that cost pressures do not undermine values such as universalcoverage and equitable financing and access”. Thomson,S. et.al. 2007 in: ‘Financing health carein the European Union Challenges and policy responses’ WHO publication, ISBN 9789289041652
[ 2 ] (section 2.1 page 3) HC a fast growing business and biggest sectors of employment. The example ofthe United States is used here: As the largest industry in the US in 2006, health careprovided 14 million jobs—13.6 million jobs for wage and salary workers and about438,000 jobs for the self-employed. 7 of the 20 fastest growing occupations are healthcare related. Health care will generate in the US 3 million new wage and salary jobsbetween 2006 and 2016, more than any other industry. US Bureau of Labor Statistics,http://www.bls.gov/oco/cg/cgs035.htm
[ 3 ] (section 2.1 page 3) HC depends to be financed through social budgets and insurances. The situationof the state wealth influences the availability of health services in the society. In the US“Economists have found that rising health care costs correlate with significant drops inhealth insurance coverage, and national surveys also show that the primary reasonpeople are uninsured is due to the high and escalating cost of health insurancecoverage” The Henry J. Kaiser Family Foundation. The Uninsured: A Primer, Key Facts About Americanswithout Health Insurance. 2009. April 2009
[ 4 ] (section 2.1 page 3) HC costs are growing faster than GDP: “National health expenditures are expected toincrease faster than the growth in GDP: between 2008 and 2018, the average increasein national health expenditures is expected to be 6.2 percent per year, while the GDP isexpected to increase only 4.1 percent per year” Siska, A, et al., Health Spending ProjectionsThrough 2018: Recession Effects Add Uncertainty to The Outlook Health Affairs, March/April 2009; 28(2):p346-357
[ 5 ] (section 2.1 page 3) There is a growing financing deficit of HC: “If the United States managed to containhealth care costs, so that apart from demographic factors they grew at the same rate asnominal GDP, then the projected deficit would be equal to just 1.5 percent of futureGDP, or $10 trillion.” Baker,D. Rosnick,D. 2003 ‘The Forty-Four Trillion Dollar Deficit Scare’, Center forEconomic and Policy Research, Briefing Paper
[ 6 ] (section 2.1 page 3) Demographic shift and increased multimorbidity. “Multimorbidity is a highly frequentcondition in older people… Little is known about the long term impact of multimorbidityon the patients' life expectancy, functional status and quality of life as well as healthcare utilization over time.” Schaefer,I. et al., The German Multicare-Study: Patterns of Multimorbidity inPrimary Health Care – Protocol of a Prospective Cohort Study, BMC Health Services Research, 11.08.2009
[ 7 ] (section 2.1 page 3) Mass health misbehavior and the world wide wave of obesity: “Health misbehaviorwhich is deliberate non-compliance… can be viewed in the larger context of healthbehavior” Gochman,D. 2003, Handbook of Health Behavior Research III, page 239,ISBN 978-0306454431
 (section 2.1 page 3) Hospitals use around 30% of HC budget : “Hospitals in Germany consume by far the greatest part, 35 %, of health expenditure by the statutory health insurance funds, and the long-range trend tracks a strong rise. Given the increasing capital intensity of hospital services in the future and high personnel costs for the clinics, a regulatory framework encouraging hospitals to operate more efficiently is imperative.” Hess,W. Economic Research Allianz Group/Dresdner Bank, Working Paper July 25th 2005, page 1
 (section 2.1 page 3) Focus on influencing Hospital HC cost being a big cost factor: “Utilization review is seen as providing a potential for cost containment (in hospitals), acting directly on the process of care rather than on reimbursement…The author concludes that a combination of cost-containment programs acting in concert needs to be applied; a lone approach will not succeed.” Zubkoff,M. et al. 2007 ‘Hospital cost containment: selected notes for future policy’, page 10, ISBN 978-0882020686
 (section 2.3.2 page 6) The handover of the final wound closing procedure during an operation from a senior surgeon to an assistant doctor is a standard procedure in teaching hospitals. The necessity for a teaching experience can easily prolong the scheduled operating time for 30 min which may be 30% of the total operating time.
 (section 2.3.4 page 7) The collision of work sequences can threaten the hygiene performance particularly. In this open space theatre the instrument support nurse touches the instrument trolleys from the ongoing operation while she has to pass with equipment for the next operating space. These work sequence collisions lead to serious quality performance problems. Frequently the work sequence collisions are neglected as they fall in the assumption trap because optimal transfer procedures have been assumed during the planning process. Unfortunately these optimal assumptions for perfectly coordinated work sequences do not reflect the reality in the daily routine of operating departments.
 (section 2.3.4 page 7) The collision of work sequences can lead to serious hygiene performance gaps in the OR. In the shown case the instrument support nurse (“jumper”) is forced to interfere with the ongoing highly sensitive orthopedic operation. By touching the sterile instrument tables there is a risk of cross-contamination and as well a disturbance of the clean airflow in the laminar stream. Again work sequence collisions (ongoing operation - - transport of goods for the next operation in the adjacent OR-field has not been made transparent during the planning of this open-plan OR.
 (section 2.4.1 page 8) „An integral management of operating rooms together with the inpatient and ambulant ward capacities has proven to be an essential prerequisite for a cost-conscious resource planning. The space allocation of the functions within the operating department must support the efforts for an efficiency increase in such a way that the high demands for total medical quality and hygiene are not impeded.”(Guthknecht 1999 Quality and Costs, How to marry two enemies: Planning and Cost Control for Future Health Facilities)
[ 14 ] (section 2.4.1 page 8) The economic success of the operating department is essentially depending upon anoptimal time-efficient workflow. If the operating department is depending upon theperformance of individual wards to bring the patient in time, the OR performance isworking without “Fault-tolerance-buffer” . This means that without a “Fault-tolerancebuffer”the operating department is not in the necessary way in control of the workflow iftiming mistakes of other departments lead immediately to prolonged operating time.
[ 15 ] (section 2.4.1 page 8) Since the reform of the DIN 1946, part 4 laminar airflow units may operate with 90% recirculatingair and 10% fresh air intake. In the instrument preparation rooms this isparticularly attractive as in absence of dangerous anesthesia gas there is even no needfor a scavenging system (separate suction of exhaled anesthesia gas). This reduces theinvestment cost by 90 % for a laminar airflow field from approximately 450’000€ to 45’000€. Additionally the running costs are significantly less, especially because ofreduced heating / cooling humidifying during re-circulation.
[ 16 ] (section 2.4.2 page 9) HOSPITAL HYGIENE IN THE 3rd MILLENIUM (Nickl-Weller, 2005, page 30):„Fazit:With the ‘Berne model’ a new development was introduced which broke trough the rigidstructures of the ‘functionalists’ and led to fundamentally new planning considerations.For the architect this means:- A clearly structured spatial layout concept.- Questioning of the validity of requirements.- Design quality, creation of privacy and intimitätRequirements for medical technology:- functional adequate technical equipment- more tidiness in the ORRequirements for hygiene:- precise statements what is necessary- comprehensible, for all spatial research ascertained requirements,not based on opinion of single persons.
[ 17 ] (section 2.5 page 10) The cost of health care building construction in the US may exceed in 2011 US$ 70billion(Zimring et al. 2008). With the overall health care cost of 2.5 trillion the 70 billionrepresent about 3% of the total health care budget. This proportion is comparable to thefigures of countries like Germany.
[ 18 ] (section 2.5 page 10) The cost of obesity varies, as according to CDC it has to be considered whatconsequential diseases are taken into account: In 2007 total cost of obesity in the USwas estimated 117 billion US$ “A sustained 10% weight loss will reduce an overweightperson’s lifetime medical costs by $2,200–$5,300 by lowering costs associated withhypertension, type 2 diabetes, heart disease, stroke, and high cholesterol.” (see www.cdc.gov)
[ 19 ] (section 2.5 page 10) The cost of diabetes is growing exponentially worldwide. The data of Germany areindicative for OECD countries. In 1995 4 million (out of 82mill. in FRG= 4.8%) sufferedfrom diabetes and caused 13 billion € in treatment cost.Estimates for 2010 foresee 10 million Diabetes cases in Germany =12% of thepopulation and 37 billion € in treatment cost.Estimates for Germany in 2025 foresee 15 million cases causing 48 billion € intreatment cost.WHO estimate that today’s world wide case figures of around 250 million could go up to380 million in 2025 causing annually 700 billion€ in treatment cost.Data for Switzerland are more favorable but show the same growth trend.(see www.gesundheit.de)
[ 20 ] (section 2.7.2 page 12) Prof. Walther Gabelmann was director of the German ‘Planungsinstitut für MedizinischeUniversitätsbauten (PMU), Freiburg, Germany. The statement was made in the contextof the PhD of the author where Professor Gabelmann acted as an advisor and evaluatorof the study
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