HEALTHCARE FACILITIES Planning, Design, Construction & Operations Healthcare Reform and the Implications to Our Industry What Lies Ahead?

Transcription

1 HEALTHCARE FACILITIES Planning, Design, Construction & Operations Healthcare Reform and the Implications to Our Industry What Lies Ahead? January, 2013 York Chan, CHFM

2 YORK CHAN, CHFM Administrator of Facilities Board of Directors Environment of Care Advisory Board Faculty Environment of Care, Life Safety Board of Directors Editorial Advisory Board 2

3 HEALTHCARE AS AN INDUSTRY There is no slowdown in healthcare Baby Boomers are in their 60 s and living longer, therefore requiring more healthcare services Enrollment in the Medicare Program is projected to nearly double in the next 30 years ENROLLMENT (MILLIONS) Actual Year Projected Source: Medicare Trustee Report 3

4 HEALTHCARE AS AN INDUSTRY Americans are not getting any healthier In % of population were classified as obese* In %* Increases in: Cardiovascular disease Type 2 diabetes Hypertension * 4

5 HEALTHCARE AS AN INDUSTRY The poorest third of British is healthier than the richest third of Americans for diabetes, hypertension, all heart disease and cancer.* Almost 80% of workers have at least one chronic disease, 50% have more than one chronic condition** *JAMA 2006; 295: ** 2009 Almanac of Chronic Diseases, May 14,

6 Insurance Focus on Wellness Growing interest in workplace disease prevention and wellness programs Medical costs fall by $3.27 for every dollar spent on wellness programs* Absenteeism costs fall by $2.73 for every dollar spent* *Health Affairs, April

7 HEALTHCARE COSTS IN THE U.S. Average spending on health per capita ($US PPP) United States Canada France Germany Netherlands United Kingdom Data: OECD Health Data 2009 (June 2009)

8 HEALTHCARE COSTS IN THE U.S. Healthcare Technology News, Jan. 12,

9 SPENDING MORE ON HEALTHCARE DOES NOT EQUATE TO LIVING LONGER Deaths per 100,000 population* France Australia Italy Japan Sweden Norway Netherlands Austria Finland Germany Greece Ireland New Zealand Denmark United Kingdom United States * Countries age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S. Source: Adapted from E. Nolte and M. McKee, Variations in Amenable Mortality Trends in 16 High-Income Nations, Health Policy, published online Sept. 12,

10 REFORM WHAT DOES THAT MEAN? Exploding Health Care costs pose one of the greatest threats, not just to the wellbeing of our families and the prosperity of our businesses, but to the very foundation of our economy. If we don t tackle Health Care, then we re going to break the bank. President Barack Obama White House Health Care Summit March 6,

11 HEALTH CARE REFORM Signed into law March 23, 2010 Patient Protection and Affordable Care Act Health Care and Education Reconciliation Act of 2010 Expand healthcare coverage to an estimated 32 million Americans Individuals with incomes up to 133% of federal poverty level would be covered by Medicaid At a cost of $940 Billion Trying to reduce the federal deficit at the same time 11

12 HEALTH CARE REFORM Substantial reductions to federal funding for Medicare and Medicaid hospital programs Initial estimate of impact to Chicago area hospitals is an $8 billion loss in Medicare reimbursement* Hardest hit will be hospitals serving large numbers of low-income, uninsured and underinsured patients * Metropolitan Chicago Healthcare Council 12

13 REIMBURSEMENTS BASED ON QUALITY Oct. 1, 2008 Hospitals stopped getting reimbursed for conditions that were not present upon admission (partial list) Surgical site infections Pressure ulcers (bed sores) Foreign objects retained after surgery Catheter related infections Complications from falls Blood incompatibility Signs of Uncontrolled Blood Sugar 13

14 REIMBURSEMENTS BASED ON QUALITY The Obama Administration has proposed payment reductions for readmissions Result of incomplete treatment or poor care Poor coordination of services at discharge 18% of Medicare patients are readmitted within 30 days of discharge* $12 Billion worth of readmissions were avoidable Readmissions within 30 days will not be reimbursed *Crain s Chicago Healthcare April,

15 BUNDLING OF PAYMENTS Proposed Bundling of reimbursements will lower reimbursements to hospitals Defined as all services from initial hospitalization through 60 days after discharge, including readmissions, physicians fees, SNF etc. One fee per episode Regardless of how many tests Increase in Accountable Care Organizations (ACO s) 15

16 QUALITY & VALUE Reimbursements will be based on quality outcomes Quality outcomes are available to the public Patients can check hospital scores on line Increased competition based on scores Increased efficiencies will lead to lowering operational costs Efficient healthcare models already exist Inefficient organizations will fall by the wayside or taken over by efficient ones 16

17 Payment Based on Performance Hospital Value Based Purchasing Program (HVBP) Beginning in FY 2013 (Oct 1, 2012), hospitals will be paid based on their actual performance on quality measures* Clinical outcomes will count for 70% Patient experience (satisfaction) will count for 30% * AHA Special Bulletin April 29,

18 Clinical Quality Measures Data is required to be reported on a quarterly basis (partial list) Surgery patients who were given an antibiotic at the right time to help prevent infection Heart Attack Patients Given Aspirin at Arrival Peri-surgical patient body temperatures Heart surgery patients blood sugar is kept under control in the days right after surgery Surgery patients needing hair removed from the surgical area before surgery, who had hair removed using a safer method 18

19 Clinical Quality Measures Data is required to be reported on an annual basis (partial list, 18 total) Death rate and rate of readmission for heart attack patients Death rate and rate of readmission for pneumonia patients Healthcare Associated Infections (HAIs) Hospital Acquired Conditions Serious Complications and Deaths Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy 19

20 Patients' Hospital Experiences Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Partial List (Partial List, 10 total) How quiet was your room Cleanliness of the environment Patients who reported that they "Always" received help as soon as they wanted Patients who reported YES, they would definitely recommend the hospital. 20

21 Trends In Hospital Consolidation To succeed in a health reform world, hospitals will need to make investments in quality, safety, electronic records, etc. Many stand-alone community hospitals will have difficulties dealing with future constraints on reimbursement from payers and demands to operate more efficiently Bundling of payments No payment for hospital acquired complications Oct. 1, 2008 No payment for re-admissions Oct. 1,

22 Trends In Hospital Consolidation Hospital mergers are up 20%* Combining with a larger operator would give independent hospitals access to deeper financial resources Healthcare systems have more access to capital Investors are leery of investing in individual operations Total profit margin, non-profit hospitals** 1st Quartile percent. 2nd Quartile 4.04 percent. 3rd Quartile 0.15 percent. 4th Quartile percent * Becker s Hospital Review, March 14, 2011 **Healthcare: Hospital Review, Nov

23 Aging Facilities A lot of hospitals have aging plants that need significant rehab or new building Average age of a U.S. hospital power plant is 40+ years old* ASHRAE s service life expectancy for: Chillers 23 Years Boilers 24 Years (water tube) 25 Years (fire tube) Fans 25 Years (centrifugal) 20 Years (axial) Operational efficiencies and reliability in question * Health Facilities Management, Feb

24 Focus on Maintenance Practices Written strategies identify the activities for Maintaining Inspection Testing Strategies may include Predictive maintenance Reliability-centered maintenance Interval based maintenance Corrective maintenance Metered maintenance Manufacture s recommendations 24

25 REGULATORY CHALLENGES Highly regulated industry (Everyone has jurisdiction!) Conditions of Participation (COP) Requirements Rules that all hospital must follow if they receive federal funding Center for Medicaid and Medicare Services (CMS) Division of Health and Human Services Joint Commission, HFAP, DNV Have received Deemed Status from CMS State Departments of Public Health Illinois Department of Public Health Hospital Licensure COP Enforcement Local Municipal Authorities EPA, DOT, OSHA, etc. 25

26 CODES & STANDARDS CMS, Joint Commission, IDPH Life Safety Code Edition Veterans Administration and the Rest of the World Life Safety Code Edition Health care facilities in the United States waste approximately $5 billion per year in construction costs associate with these antiquated building codes Less than 1 death per year from fire in U.S. hospitals 26

27 CODES & STANDARDS CMS, IDPH NFPA-99 Operating Room Humidity 35% to 60% Joint Commission FGI Guidelines for the Design and Construction of Healthcare Facilities 2010 ASHRAE 170 Ventilation of Healthcare Facilities Operating Room Humidity 20% to 60% Change from 35% to 20% minimum would save $200 million in healthcare construction and energy costs over 10 years* 27

28 Joint Commission Findings Top 11 out of 20 are Building Related Top 20 Rank Standard 1 st Half 2012 RFIs 2011 RFIs 2 LS % 56% Means of Egress Subject 3 LS % 52% General LSC Requirements 4 EC % 40% Features of Fire Safety 7 LS % 45% Life Safety Protection 8 LS % 31% Fire Suppression Systems 9 EC % 29% Built Environment 10 EC % 23% Hazardous Materials & Waste 11 EC % 25% Utility Systems (Ventilation) 16 EC % 22% Medical Gases 17 EC % 26% Emergency Power 20 EC % 21% Fire Safety 28

29 #9: EC % EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment and services provided The organization must provide a safe environment 29

30 #9: EC % EP 13 The organization maintains ventilation, temperature and humidity levels suitable for the care, treatment and services provided Ventilation: i.e. doors held open by air pressure; odors Temperature: Hot / Cold calls Humidity Primary concern is for areas >60%RH Mold growth is possible 30

31 #11: EC % EC EP 1: Improper system design Inability of the mechanical system to achieve required results EC EP 4: Lack of written inspection, testing & maintaining frequencies Continuous monitoring by a building automation system (BAS) is acceptable 31

32 #11: EC % EC EP 6: Ventilation system is unable to provide appropriate pressure relationships, airexchange rates and filtration efficiencies Specific areas lack negative or positive pressures in relationship to adjacent areas i.e. Endoscopy Processing Room should be negative to the egress corridor the correct number of air changes per hour Improper filtration MERV = minimum efficiency reporting value 32

33 HOW CAN THE DESIGN & CONSTRUCTION INDUSTRY AFFECT CLINICAL OUTCOMES? Facilities design professionals, constructors and facilities managers must partner with clinical staff to improve clinical outcomes! 98,000 Deaths a year from adverse events after admission Hospital acquired infections, medication errors, wrong site surgeries, etc. 4th leading cause of death Greater than motor vehicle accidents, breast cancer, or AIDS Less than 1 death per year from fire related events in hospitals We spend millions per year to ensure no fires 33

34 HOW CAN THE DESIGN & CONSTRUCTION INDUSTRY AFFECT CLINICAL OUTCOMES? Evidence Based Design Private rooms for improved infection control Private rooms lessen the chance for errors Wrong patient in the same room confusion Same sided rooms lessen the chance for errors and improve efficiency All equipment and supplies are in the same place in every room Travel distances from bed to bathroom Majority of patient falls occur to and from toileting 34

35 WORKING WITHIN A HOSPITAL SETTING Contractors must adhere closely to Infection Prevention assessments and measures Aspergillus spores (mold); found in the earth (dirt) Spores light, float easily in air, carried into ventilation Resilient, can lay dormant for years; re-activates with moisture, humidity and a food source (decaying cellulose) 35

36 HOSPITAL ACQUIRED INFECTIONS Est. Annual Cost of Treatment $5 Billion CMS No Pay - patients cannot be billed Surgical patients who acquire HAI infections 6.5 more days in the hospital, 5 times more likely to be readmitted, two times more likely to die Average costs to treat - $13,973 36

37 WORKING WITHIN A HOSPITAL SETTING Air exchanges, pressure relationships with adjoining spaces, etc., are all high priorities Protection of patients, staff and visitors from the hazards of construction Hospitals will be looking towards Certified healthcare constructors 37

38 HOSPITAL ACQUIRED INFECTIONS Air Handling Systems Filtration Humidification Pressurization Clean to Less Clean Airflows Positive for O.R./Surgery, Immuno-compromised patients Negative for infectious patients, soiled storage Air Exchanges Hourly Air Changes for Dilution Preventive Maintenance 38

39 OPERATING ROOM TEMPERATURES It is a myth that O.R. s are kept cold for infection control reasons. Main reason O.R. s are kept so cold is for the comfort of the surgeon. Clinical trials have shown that perioperative normothermia (36.5 degrees C) in patients undergoing surgery has been shown to reduce infection rates. Perioperative hypothermia (34.5 degrees C) may promote surgical wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension. Hypothermia also affects other body parts such as liver functions and blood coagulation. 39

40 UTILIZE TECHNOLOGY Use technology as much as possible Monitor temperature and humidity parameters, air exchanges, room air pressure relationships Constant monitoring versus snap shot of conditions Take out the human elements Building automation systems to maximize efficiencies Utilize software to track environmental rounds 40

41 EFFICIENCY Energy costs are currently at a ten year low but is not going to last forever Healthcare is way behind other industries in the area of energy efficiency Still plenty of low hanging fruit Every dollar saved is the equivalent of the organization not having to seek twenty dollars in new business In-house labor costs Outside contracted services Energy Costs 41

42 Commissioning HFCx Standard For All Healthcare Projects Retro Cx to improve energy efficiency of Existing Facilities Continuous Commissioning to Optimize the Built Environment Need to sell the C Suite the value of commissioning Better patient, employee and visitor comfort Less service calls Better clinical outcomes Contributes to the bottom line 42

43 MOVING FORWARD Quality will be the ultimate driver Hospitals will have to be designed, constructed and maintained with patient quality outcomes as the main focus Facility Operations are always looked upon as non-revenue generating services. We have to show that we can contribute to quality clinical outcomes of our patients Clinical services and equipment are considered money makers 43

44 What People Want VALUE = (Access + Quality + Security) Cost 44

45 MOVING FORWARD To be successful in the healthcare arena, Designers, Architects, Consulting Engineers, Contractors and Facility Managers must be able to show how they contribute to: Quality Patient Outcomes And Value 45

46 QUESTIONS? YORK CHAN, CHFM (630)