Inspections of health care facilities reveal challenges and opportunities

Don D. King, CHFM, BEP, Chad E. Beebe AIA, CHFM, Joan L. Suchomel AIA, ACHA, EDAC, Peter L. Bardwell FAIA, FACHA and Vincent Della Donna, AIA, ACHA

Given the size and scope of the country’s healthcare infrastructure and its mission to save lives and promote health, it’s no wonder that its conditions and ability to operate at its best is a vital national priority.

This huge system has 5,627 registered hospitals in the United States, with a total of more than 900,000 beds and a total budget of nearly 900 billion US dollars. It provides a series of buildings, engineering systems and technologies that can serve the well-being and economic strength of the United States.

By the end of 2017, this does not include the estimated 2,800 retail medical clinics operating in the United States, and this number is expected to increase.

Recognizing these facts, the American Society of Healthcare Engineering (ASHE) and the American Institute of Architects School of Health Architecture published an ASHE monograph on “The State of American Healthcare Facilities Infrastructure”, which is excerpted here.

Facility condition
The overall state of the U.S. healthcare infrastructure varies greatly. Hospitals with strong market positioning and forward-looking leadership have invested in maintenance and modernization, but some hospitals in struggling communities cannot keep up.

The two key indicators of health care facility status are age of factory (AoP) and facility status index (FCI).

The reliability of indicators affects benchmark testing

AoP is not a direct indicator of physical age; instead, it is a financial ratio that measures the extent to which hospitals have updated their facilities. This ratio is calculated as accumulated depreciation and depreciation expenses. This AoP indicator has been reported in multiple agencies and its median value has been published (to correct for extreme outliers). The final median AoP score allows the site to understand the overall condition of the hospital’s infrastructure in any given time period and to track patterns over many years.

For example, the median average age of plants in U.S. hospitals in 2015 was 10.78 to 11.48 years (depending on the source of publication), compared to 9.8 to 9.96 years in 2004 and 8.6 in 1994. In the past two decades, nearly three years show that, overall, the hospital has been working hard to raise funds to keep its facilities up to date.

Even with the conservatively reported (lower) plant measurement age, this upward trend in AoP can be clearly noticed, as shown in the chart on page 20.

Specifically, the graph illustrates the year-to-year changes in the calculated plant age indicators, where the y-axis represents the age of the plant (reported as the median), the x-axis represents the year of the report, and the line represents each data point connected. The upward trend is clearly visible. When evaluating the difference between the AoP in 2000 and the latest AoP score in 2015, the difference is statistically significant and has a moderate impact on AoP over the entire time frame, which proves the following point: U.S. hospital infrastructure may benefit from investment.

Although the median AoP can be a reasonable substitute for the status of the infrastructure of health care facilities, most health care organizations will conduct detailed facility status assessments. These assessments provide specific information about deferred maintenance needs and their estimated costs. These data are used to calculate FCI, the most commonly used indicator for measuring facility conditions. The FCI formula is that the cost of repairing facilities exceeds the cost of replacing facilities.

Unfortunately, there is no FCI comparative data available, because FCI is most often used as a benchmark for medical institutions, rather than as an indicator for reporting and archiving. In view of the many factors that affect FCI (for example, the geographical and demand-based differences in maintenance market costs, when should the subjective assessment of maintenance be carried out), this indicator is usually used for internal purposes and therefore cannot be compared between different plants in different regions .

In fact, most consultants and heads of healthcare organizations agree that the FCI value of buildings with key functions (such as hospitals and nursing centers) should be 0.05. For other less important buildings (for example, outpatient clinics and administrative offices), the FCI target is close to 0.10.

FCI of 0.15 means that the deferred maintenance cost is equal to 15% of the total replacement equipment cost. For these facilities, systems and components (such as panels, pipes and wires, and patient care systems (such as medical gas)) may be as outdated as the physical structure (replacement parts are hardly found because they are no longer available). Or at least, systems with medium to long lifetimes (such as machinery, vertical transportation and roofing) have exceeded their lifetimes.

When facilities cannot meet maintenance requirements, the risk of failure increases. For example, a hospital in the Midwest postponed maintenance of an aging elevator system to save costs. When the elevator suddenly stops working, the consequent financial loss and loss of productivity are many times higher than the cost of the hospital’s delay in maintaining the elevator.

In fact, an analyst calculated that waiting for replacement until a part or system fails will eventually cost the organization the replacement cost. For example, if a hospital decides to postpone maintenance of an aging water heater to save $500, the hospital may end up losing $250,000 when the water heater leaks through the floor and damages adjacent floors and walls.

This relative deterioration of health care facilities seems to be a national concern, because in a 2010 survey of the Healthcare Finance Management Association, one-third of chief financial officers (CFO) reported that, Their hospital condition is worse than 10 years ago. . In addition, half of the CFOs surveyed reported that their infrastructure deteriorated faster than their capital improved.

Capital allocation
According to ASHE’s Healthcare Executive Leadership Committee, most healthcare organizations develop complex multi-year plans to determine where to use their funds. Some of the key factors used to develop these plans include:

A brief history of U.S. health facilities portfolio

Condition|Major health care organizations regularly measure the condition of their facilities. Although the most commonly used measure is FCI, some organizations simply create a high-priority list of systems based on the urgency of replacement. Usually, these assessments are enhanced by sophisticated analyses that take into account the service life of the equipment, maintenance records, failure consequences, replacement costs and other factors.

Tasks|Some capital allocation supports the organization’s tasks, rather than alleviating conditions. For example, a hospital located in an area with an aging population may decide to establish a skilled nursing facility to serve the community.

Potential return on investment|The possible rate of return on capital allocation can also play an important role. For example, sometimes investment in energy efficiency can quickly offset the investment. For example, a large academic medical center in the Midwest used the energy savings from a major upgrade of its factory to pay $50 million for the renovation of other facilities.

Market demand|Consumerism is about meeting with patients. These ever-changing markets have changed strategy and thus changed capital priorities. For example, most of the capital investment in a medical system goes to outpatient areas.

Brand Image|Many hospitals strive to build facilities that foster confidence, expertise, and compassion. Facts have shown that the layout of buildings, interior design and architecture are “intangible assets” together with clinical care.

Decoration investment
The main motivations for investing in retrofit projects include:

Hospital Modernization|Many older hospitals have surgical and diagnostic/treatment areas that do not meet current standards of practice for patient safety and infection control. The data shows that rural hospitals and hospitals with fewer than 400 beds are on average slightly older than other hospitals, and their quality scores are slightly lower.

Bed modernization|Many elderly hospitals either do not have enough functions, do not have standard wards, or do not meet

Life Safety System|Many older hospital buildings may not have sufficient personal safety infrastructure to adapt to the new, more urgent nature of hospital care. The joint committee representing hospitals accredited by the Medicare and Medicaid Services Center announced that 21 performance elements have been added to their lives,
Safety requirements for hospitals in early 2017. These new requirements, including the installation of sprinklers in closets and ensuring that oxygen tanks are stored in locked confined spaces, will increase pressure on hospitals whose current systems do not meet these standards.

New construction investment
The main motivations for investing in new construction projects include:

Population Health Initiatives | These initiatives aim to provide medical services outside the hospital and emphasize the growing demand for independent structures with unique, timely, dual functions and innovative medical purposes. These facilities include health clinics, fitness centers, immunization clinics, home-school health centers with grocery stores and cooking centers, and other health-promoting facilities.

Outpatient | The advanced healthcare system recognizes that staying overnight in a hospital is not only expensive, but also unnecessary in many cases. As a result, these organizations are increasingly building facilities to accommodate the growth of outpatient services such as day surgery centers.

Mental Health|In the past few decades, the de-institutionalization of mental health people has appeared. Federal and local governments have cut mental health funding and closed mental health facilities, but studies have shown that mental disorders, especially dual diagnosis disorders, are the most expensive diseases in the United States. This news, coupled with the latest report from the US Centers for Disease Control and Prevention, points out that drug-related deaths have increased by 137%, and opioid-related deaths have increased by 200%, which clearly shows the importance of other mental health services. Demand.

Safety Net Clinics|Many public and private clinics that serve low-income patients provide basic community health and primary care services while receiving marginal reimbursement. These facilities rely on payment sources that are often complex and difficult to navigate to stay open. Given the increasing pressure to provide the most affordable medical services to the growing number of disadvantaged populations, it is reasonable to expect that there will be greater demand for such treatment facilities.

Indian Health Services|The infrastructure to support the provision of medical services to Native Americans is severely inadequate. After the displacement of Native Americans more than a hundred years ago, according to the treaty, the Indian Health Service provided services to 2.2 million people. A 2014 report from the Ministry of Health and Human Services found that “outdated and insufficient buildings and equipment” threatened the quality of care for this population.

Department of Veterans Affairs (VA) Facilities | Many veterans encounter unacceptable waiting services, some of which are caused by insufficient facilities. Recent data indicate that certain health care quality measures in Virginia medical institutions continue to deteriorate, including the increasing rate of catheter-related infections and complications in the hospital. Increased investment in facilities in Virginia will improve the health and care of American veterans.

Responsible investment
The US healthcare infrastructure is in poor condition, but it is aging. As with anything obsolete, it requires more resources to keep existing facilities in top operating condition. Some professionally recognized and verified indicators show that investment in these resources has decreased.

Therefore, early and responsible financial investment in U.S. healthcare infrastructure can alleviate this trend, increase safety and improve performance, and ultimately enable the country to allocate more resources to guide patient care.

In addition, health care organizations now more than ever require qualified and motivated professionals to maintain and operate health care facilities.

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