Cost-Effectiveness of Multifaceted Built Environment Interventions for Reducing Transmission of Pathogenic Bacteria in Healthcare Facilities.

OBJECTIVES: The objective of this study is to determine the optimal allocation of budgets for pairs of alterations that reduce pathogenic bacterial transmission. Three alterations of the built environment are examined: handwashing stations (HW), relative humidity control (RH), and negatively pressured treatment rooms (NP). These interventions were evaluated to minimize total cost of healthcare-associated infections (HAIs), including medical and litigation costs. BACKGROUND: HAIs are largely preventable but are difficult to control because of their multiple mechanisms of transmission. Moreover, the costs of HAIs and resulting mortality are increasing with the latest estimates at US$9.8 billion annually. METHOD: Using 6 years of longitudinal multidrug-resistant infection data, we simulated the transmission of pathogenic bacteria and the infection control efforts of the three alterations using Chamchod and Ruan's model. We determined the optimal budget allocations among the alterations by representing them under Karush-Kuhn-Tucker conditions for this nonlinear optimization problem. RESULTS: We examined 24 scenarios using three virulence levels across three facility sizes with varying budget levels. We found that in general, most of the budget is allocated to the NP or RH alterations in each intervention. At lower budgets, however, it was necessary to use the lower cost alterations, HW or RH. CONCLUSIONS: Mathematical optimization offers healthcare enterprise executives and engineers a tool to assist with the design of safer healthcare facilities within a fiscally constrained environment. Herein, models were developed for the optimal allocation of funds between HW, RH, and negatively pressured treatment rooms (NP) to best reduce HAIs. Specific strategies vary by facility size and virulence.

Proton Facility Economics: Single-Room Centers.

OBJECTIVE: We have previously described the central nature of simple cases for financial feasibility of proton beam therapy centers-especially four- to five-room centers. In the 5 years since that publication, such construction has slowed drastically, and smaller, single-room projects are in vogue. We now seek to show under what circumstances a single-room system is optimally financially viable. MATERIALS AND METHODS: A "standard" construction cost and debt for a single gantry system of $40 million was presumed, with 75% of the construction funded through standard 20-year financing. We then modeled a statistical analysis, deriving the optimal case mix required daily to cover construction and debt service costs. RESULTS: We previously published that a single gantry treating only complex patients would need to apply 85% of its treatment slots simply to service debt, though it would cover its debt treating 4 hours of simple patients. As the business model has changed, debt maintenance, profit and operational costs have somewhat reduced the business case for adding a large number of simple patients. Debt maintenance is possible with as little as 13% of daily patients for a 40% Medicare case mix, but these numbers are critically sensitive to continued patient throughput. CONCLUSIONS: Even in a single-room system, reducing overall debt, using tax-exempt financing, and having a case load emphasizing simple, private payer patients is paramount to fiscal health of the facility. Unused capacity is a huge risk if insufficient patients are available.

Advancing indigent healthcare services through adaptive reuse: repurposing abandoned buildings as medical clinics for disadvantaged populations.

BACKGROUND: Challenges abound for healthcare providers engaged in initiatives directed toward disadvantaged populations, with financial constraints representing one of the most prominent hardships. Society's less fortunate typically lack the means to pay for healthcare services and even when they are covered by government health insurance programs, reimbursement shortcomings often occur, placing funding burdens on the shoulders of establishments dedicated to serving those of limited means. For such charitably-minded organizations, efficiencies are required on all fronts, including one which involves significant operational costs: the physical space required for care provision. DISCUSSION: Newly constructed buildings, whether owned or leased, are expensive, consuming a significant percentage of funds that otherwise could be directed toward patient care. Such costs can even prohibit the delivery of services to indigent populations altogether. But through adaptive reuse-the practice of repurposing existing, abandoned buildings, placing them back into service in pursuit of new missions-opportunities exist to economize on this front, allowing healthcare providers to acquire operational space at a discount. In an effort to shore up related knowledge, this article profiles Willis-Knighton Health System's development of Project NeighborHealth, an indigent clinic network which was significantly bolstered by the economies associated with adaptive reuse. CONCLUSIONS: Despite its potential to bolster healthcare initiatives directed toward the medically underserved by presenting more affordable options for acquiring operational space, adaptive reuse remains relatively obscure, diminishing opportunities for providers to take advantage of its many benefits. By shedding light on this repurposing approach, healthcare providers will have a better understanding of adaptive reuse, enabling them to make use of the practice to improve the depth and breadth of healthcare services available to disadvantaged populations.

Full marks achieved for Pinderfields eye clinic.

Jon Newman, managing director of Elliott, explains how an off-site construction system enabled the completion of a specialist eye clinic at Pinderfields Hospital in Wakefield in just 32 weeks.

Do cost savings from reductions in nosocomial infections justify additional costs of single-bed rooms in intensive care units? A simulation case study.

PURPOSE: Evidence shows that single-patient rooms can play an important role in preventing cross-transmission and reducing nosocomial infections in intensive care units (ICUs). This case study investigated whether cost savings from reductions in nosocomial infections justify the additional construction and operation costs of single-bed rooms in ICUs. MATERIALS AND METHODS: We conducted deterministic and probabilistic return-on-investment analyses of converting the space occupied by open-bay rooms to single-bed rooms in an exemplary ICU. We used the findings of a study of an actual ICU in which the association between the locations of patients in single-bed vs open-bay rooms with infection risk was evaluated. RESULTS: Despite uncertainty in the estimates of costs, infection risks, and length of stay, the cost savings from the reduction of nosocomial infections in single-bed rooms in this case substantially outweighed additional construction and operation expenses. The mean value of internal rate of return over a 5-year analysis period was 56.18% (95% credible interval, 55.34%-57.02%). CONCLUSIONS: This case study shows that although single-patient rooms are more costly to build and operate, they can result in substantial savings compared with open-bay rooms by avoiding costs associated with nosocomial infections.

Adding Value by Hospital Real Estate: An Exploration of Dutch Practice.

OBJECTIVES: To explore how hospital real estate can add value to the healthcare organization, which values are prioritized in practice, and why. BACKGROUND: Dutch healthcare organizations are self-responsible for the costs and benefits of their accommodation. Meanwhile, a lively debate is going on about possible added values of corporate and public real estate in the fields of corporate real estate management and facility management. This article connects both worlds and compares insights from literature with experiences from practice. METHODS: Added values extracted from literature have been discussed with 15 chief executive officers and project leaders of recently newly built hospitals in the Netherlands. Interviewees were asked (1) which values are included in the design and management of their hospital and why, (2) to prioritize most important values from a list of nine predefined values, and (3) to explain how the chosen real estate decisions are supposed to support organizational objectives. RESULTS: Stimulating innovation, user satisfaction, and improving organizational culture are most highly valued, followed by improving productivity, reducing building costs, and creating building flexibility. Image, risk control, and financing possibilities got lower rankings. The findings have been used to develop a value-impact matrix that connects nine values to various stakeholders and possible interventions. CONCLUSION: The findings and the value-impact matrix can make different stakeholders aware of many possible added values of hospital real estate, potential synergy and conflicts between different values, and how to steer on value add in different phases of the life cycle.

Trust plays its part in Carter agenda.

With Lord Carter's recent 'Productivity and Efficiency' review suggesting some £5 bn could be saved annually by acute Trusts in England by 2020 via activities such as 'smarter' procurement and better use of existing estate, the Procurement and Commercial team at Salisbury NHS Foundation Trust have been working intensively to play their part. More efficient procurement, securing better deals on utility costs, and cutting the cost, and improving the efficiency of, sterile services activities, are among a wide range of initiatives championed by the team that have seen it deliver a £1.1 m cost reduction for the Trust in 2016-2016, with a £1.2 m saving predicted this year, and a 'value creation' of over £2 m. The Trust's commercial services team has also developed and supports an ever-expanding range of innovative new products and services, and launched spin-off companies to market them. As HEJ editor, Jonathan Baillie, discovered, these range from a bedstacker designed to reduce the number of empty hospital beds left in corridors, to a fully managed service for Trusts wanting to install solar canopies in their car parks.

Procurement options' 'pros and cons'.

The existing ProCure21+ (P21+) framework deal for delivering healthcare construction projects for the NHS is due to end this September, and will be replaced by ProCure22, which could see a spend of £2 bn - £5 bn over four years. Against this backdrop, Ian Nunn ICIOB, a senior associate at multidisciplinary design, property, and construction consultancy solutions business, Pellings, reviews the different types of procurement options open to NHS Trusts, and considers their 'pros and cons'.

Evidence-Based and Value-Based Decision Making About Healthcare Design: An Economic Evaluation of the Safety and Quality Outcomes.

OBJECTIVE: This study describes a vision and framework that can facilitate the implementation of evidence-based design (EBD), scientific knowledge base into the process of the design, construction, and operation of healthcare facilities and clarify the related safety and quality outcomes for the stakeholders. The proposed framework pairs EBD with value-driven decision making and aims to improve communication among stakeholders by providing a common analytical language. BACKGROUND: Recent EBD research indicates that the design and operation of healthcare facilities contribute to an organization's operational success by improving safety, quality, and efficiency. However, because little information is available about the financial returns of evidence-based investments, such investments are readily eliminated during the capital-investment decision-making process. METHOD: To model the proposed framework, we used engineering economy tools to evaluate the return on investments in six successful cases, identified by a literature review, in which facility design and operation interventions resulted in reductions in hospital-acquired infections, patient falls, staff injuries, and patient anxiety. RESULTS: In the evidence-based cases, calculated net present values, internal rates of return, and payback periods indicated that the long-term benefits of interventions substantially outweighed the intervention costs. This article explained a framework to develop a research-based and value-based communication language on specific interventions along the planning, design and construction, operation, and evaluation stages. CONCLUSIONS: Evidence-based and value-based design frameworks can be applied to communicate the life-cycle costs and savings of EBD interventions to stakeholders, thereby contributing to more informed decision makings and the optimization of healthcare infrastructures.

Protecting a CT simulator room to accommodate a cyberknife facility.

In 2012, a plan to develop Stereotactic treatments using a Cyberknife was unveiled at the Hermitage Medical Clinic, Dublin. Due to planning restrictions the new facility had to be contained in the existing hospital's blue print with the only available location being an unused CT simulation room. The room design would be different from conventional radiotherapy bunkers due to the fact the Cyberknife can fire an unfiltered beam in any direction bar the roof (restriction of 22° above the horizontal). Therefore all walls must be primary barriers with the roof designed to protect against the large leakage radiation resulting from the high MU's used during the treatments. Space consideration indicated that concrete alone could not be used to restrict the radiation beam to acceptable limits. To this end a combination of steel, lead, normal and heavy concrete were used to meet the dose constraints established by the Irish licensing authorities.

Part 1: Evidence-based facility design using Transforming Care at the Bedside principles.

An academic hospital used Transforming Care at the Bedside (TCAB) principles as the framework for generating evidence-based recommendations for the design of an expansion of the current hospital. The interdisciplinary team used the table of evidence-based data to advocate for a patient- and family-centered, safe, and positive work environment. A nurse project manager acted as liaison between the TCAB design team, architects, and facilities and design consultants. Part 2 of this series describes project evaluation outcomes.