Lean, green and digital

The vision for the new, state-of-the-art Humber River Hospital didn’t come overnight—it is the result of exhaustive engineering and design analysis and the belief that if you drive quality care to a higher level, you will reap the benefits of efficiency, low cost and capacity and, in the process, create a better experience for patients and families.

The newly built Humber River Hospital (HRH), which opened its doors in October 2015, is about as far from the emergency department you know as you can get. Its spaces are airy and light-filled, it’s façade shiny and colourful. But let’s not judge this book by its cover—the substance is in the pages.

A STRONG VISION

When the decision was made for HRH to move from three smaller sites to a sprawling single site, which required building a new state-of-the-art facility on the old Ontario Ministry of Transportation land in northwest Toronto, the redevelopment team analyzed its operational history and looked at how other hospitals worked, with an eye towards determining what it would take to reduce costs, improve efficiency, increase capacity and offer a better patient experience. The team especially wanted to learn how they could convert anything that might otherwise be wasted dollars into patient care. “We worked extensively with GE Healthcare on LEAN processes in each of our previous hospitals to understand what drove us back,” explains Barbara Collins, president and chief executive officer of HRH, who led the redevelopment team.

Moving to a much larger, 1.8-million-square-foot building—80 per cent of which would be single-patient rooms—meant they needed to figure out how to tackle operations without tripling their budget. Before the design of the hospital was even completed, the team trudged through a mountain of work to determine how design and technology might save them money that they could convert for use in the hospital.

To make their vision come to life, HRH enlisted the expertise of renowned architectural firm HOK, a global design, architecture, engineering and planning firm with a breathtaking portfolio. Jeff Churchill, a vice president and architect at HOK, acted as their advocate throughout the design process. “As a PPP (public-private partnership) process, we developed project-specific output specifications, we developed the main organizational moves of the hospital on the site, and we developed basic integral design principles, such as the portals of care (which reduce the need to travel long distances) and a lot of the planning that went into the hospital,” explains Churchill.

Reflecting on what needs to be considered when approaching a project of HRH’s magnitude, Churchill muses: “We were lucky to have a client who had a strong and committed vision, which turned out to be a very simple idea about lean, green and digital—and each of those aspects we innovated as much as we possibly could, within accepted tolerances of the client and the risk. And what we came out with was a synergy between those three pieces.”

SUSTAINABILITY GOALS

One of HOK’s biggest responsibilities was manifesting HRH’s sustainability goals—and, as the compliance architects, HOK set the vision for what those targets would be. Working closely with an energy modeler, they looked at each individual system, eventually coming up with the most cost-effective, long-term solution while getting the biggest energy cost-savings attainable.

The goal, across the board, was to make it as energy efficient as possible. One of the challenges was meeting HRH’s mandate for 100 per cent fresh air, which meant air could not be recirculated. To accomplish this, HOK used classic, tried and true engineering strategies. “We didn’t want to do anything that was cutting-edge or over and above what basic engineering strategies would be,” says Churchill. “We stuck to good engineering practices and good design practices to show how this target could be made.”

Churchill explains that by implementing the strategies outlined in HOK’s vision and project output specifications, coupled with the aggressive Toronto Green Standard—going beyond green roofs, fresh air and recycled water—achieving LEED Gold status was an inevitability. It ultimately made them 40.1 per cent more energy efficient than any other hospital in North America. And it was achieved without sacrificing any of the things HRH wanted, like intelligent lighting systems, room temperature and chromatic glass that can be controlled both by the patient and centrally according to time of day and seasonality, a digital pill-picker, automatic guided vehicles (AGVs) and snow-melt systems around the sidewalks so people don’t trip when they go outside in the winter.

The green aspect of HRH’s vision was a key factor in making its patient experience unique. Churchill says this was one of their top priorities from the beginning: “There’s a lot of technology implemented into this building…and some of this technology the patients will never see but it’s all in service of creating a better environment and enabling better care of the patient.”

Features such as integrated bedside terminals and monitors with access to patient care records and diagnostics, instant charting beside the bed, the ability to scan the barcodes of medications or connect with family and friends online and order food or entertainment all enhance the hospital experience. Some of it is simply about streamlining communications and tasks. Nurses are outfitted with personal devices, enabling patients to make simple requests without the need for a nurse to make multiple trips. “Patients can communicate directly with their nurse, who may be on another part of the floor, and ask them for that blanket or that ice and she doesn’t have to walk back and forth,” Churchill explains. Simple changes like this save time and reduce distractions, enabling healthcare workers to focus on front-line care, a key aim of the hospital.

INNOVATIVE NOISE CONTROL

With the patient experience top of mind, the layout of the rooms and units was designed to reduce the sounds that often disturb patients, including carefully looking at the acoustical performance of floors, door seals, and back-to-back headwalls. The fact that 80 per cent of the patient rooms are singles is conducive not just to avoiding the spread of germs but also to helping reduce noise.

“There’s an incredible amount of noise on a patient unit,” Churchill points out. “When you’re sick, you want to rest and you want peace and you want quiet—and, of course, from room to room patient noises can be very distracting, or family noises from the adjacent room, or noises from the nurse call station or collaboration that the nurses are doing.”

Churchill’s team addressed these issues by implementing team rooms for nurses to meet in and placing family areas deep into patient rooms—family members are permitted to visit 24/7—so discussions aren’t happening near open doors. Other accommodations, such as cushioning the receiving ends of the pneumatic tubes that deliver samples and medicines, and routing HVAC services through corridors and not overtop patient rooms, further minimize environmental noise. HOK worked closely with Aercoustics Engineering Limited, a firm specializing in innovations in acoustics, vibration and noise control. No opportunity was missed to create a quieter, more peaceful atmosphere.

“Traditional hospitals have been studied and have been found to be one of the worst acoustical environments from a healing perspective, and many studies have shown that the noise levels in hospitals have a direct link to the time it takes for somebody to heal,” explains Payam Ashtiani, P.Eng., principal at Aerocoustics. In addition to contending with traditional noise, the hospital was built beside Highway 401, Canada’s busiest thoroughfare. Ashtiani’s team tackled environmental noise by using acoustic models to predict sound impinging on the structure and investigated materials that could be used on the façade to mitigate sound penetrating through.

HRH’s mandate for natural light presented a challenge the team addressed by looking closely at window construction, all while ensuring that with every material introduced, be it glass or cinder block, the sound level experience inside met the intended specifications according to the model.

To create a livable environment amid the bustle of a busy hospital, the needs of its inhabitants were considered paramount by all parties, and this included addressing the integration of technology. Collins explains: “Our purpose for being here is to provide high-quality, safe patient care, and to focus on what the patient and family need. So, we took that very seriously in our design, in the patient having control over their environment, and in the fact that you can always have more people interact with patients—what you can’t do is waste those resources delivering supplies, doing things that could be automated. You need to automate to move the resources to the front line. That was our philosophy.”

In the spirit of that philosophy, HRH employs the use of AGVs—robotic sentries that buzz about the space, politely asking those who block their path to step aside as they gather dirty linens and deliver supplies. It was up to Ashtiani and his team to balance the needs of patients and staff while incorporating the volume of technology that goes into delivering an all-digital hospital—ensuring, for example, the noise from any rattling bins the AGVs might be carrying, or even their wheels, was such that if they moved past a patient’s room the patient wasn’t interrupted by the sound of them whirring by. “That was really the challenging part of this project: to ensure that we were taking care of all the pieces of digital equipment,” says Ashtiani. “Anyone who has a cellphone knows what it’s like when you get notifications and buzzing and beeping from your devices trying to get your attention. So, what the system that was developed here aims to do is to minimize the distraction to the patient and reduce the communication going on between staff. That might sound counterintuitive but the concept is that you send the communication to the people who find it relevant as opposed to the traditional PA system where they’re saying, ‘code blue’ and ‘code red’ and everybody hears it, and probably one per cent of the staff needs to use that information. And so, because all the staff here have personal devices, the notifications get sent to them directly.”

Ashtiani explains that acoustical engineering is more than just eliminating noise—it’s about making a space conducive to the sound experience it’s meant for. That means ensuring a classroom is conducive to understanding speech, a movie theatre dampens all sound except the film, a concert hall reverberates with music, and a hospital is quiet. “Controlling sound is about making sure the acoustic landscape of the space matches with the intent,” he says. “The soundscape of any area that we as humans are in has a profound effect on how we interpret that space.”

DIGITAL INFRASTRUCTURE

HRH holds the distinction of being North America’s first all-digital hospital, and the digital aspect is key to what has been achieved in terms of improving patient experience and patient care. Peter Bak, chief information officer at HRH, says the hospital’s digital vision is reflected in its design: “When we looked at the vision of digital and what that really means, we went beyond the clinical delivery, and we went into the entire building as a digital infrastructure, and the benefits that you reap from doing that.”

Bak characterizes digital hospitals by four themes: electronic information, mobile and connected, patient empowerment and systems automation. He expands on how the electronic component—with a stress on actionable information and how that drives efficiencies, workflows and quality improvements—lays the framework for the rest: “In healthcare, many people will naturally think of patient-related information such as vital signs, monitors, the patient chart and that kind of stuff, but what we recognized was that, when we think of actionable data, it should be every single piece of information that is flowing in this building.”

That means the lighting systems, elevators, HVAC systems, doors and even the chromatic glass windows are all electronic and actionable. And indeed, every single piece of mechanical-electrical equipment in the building is on an interoperable network and IP-based—something Bak says is key: “As a result, we have visibility to all our building mechanical-electrical systems, and the value of that is that it allows us to fine-tune and optimize the performance of the building with specific emphasis on energy consumption.”

A NEW COMMAND CENTRE

Two years into operation, the hospital continues to innovate, implementing a new command centre just a few months ago—an innovation born out of the need to solve a very real problem. Bak explains: “In our current system, and this is true of many nations, hospital capacities are under pressure continually, and that is because we have growing populations, aging populations, and it’s the aging population piece that impacts the acute centre more greatly than the younger populations.”

Having reached full capacity within just four months of opening HRH’s doors—despite being expected to grow into full capacity over a period of five years—they needed to come up with a solution to address the strain.

“The objective of the command centre is to drive greater efficiencies and greater quality of care—the delivery of care—and, in so doing, the premise is that you create increased capacity in your operation and you also reduce cost,” says Bak. He points out the inefficiency of hospitals, not as a critique, but as a fact due to their size and complexity, saying it all comes down to visibility: “We absolutely see how having that visibility and being able to reprioritize work leads to greater efficiency and greater capacity.”

Bak stresses it’s not that people are doing bad work and the command centre fixes it but, rather, the command centre enables the work to get done more efficiently and in priority sequence. It’s about bringing what he refers to as “meaningful visibility” to operations and optimizing patient flow: the in and out of patients.

Bak offers the example of a porter who gets a task to deliver a patient from one part of the hospital to another. That porter is unaware that there’s another patient ready for discharge waiting to be taken downstairs, and that—freeing up a bed—is a higher priority than moving the other patient from one unit to another. “They don’t see that visibility. But now the command centre presents that to you,” he says.

Using predictive analytics, the command centre can also determine where resources will be needed in the days ahead based on normal patterns of practice and activity in the organization, allowing them to plan more effectively. It takes full advantage of the digital environment, where information can be pulled from multiple sources, enabling key people to see what’s happening, work together and fix any flow problems that occur. “Even if you save a half a day for every patient in terms of flow, you start to expand your capacity without increasing costs,” says Barbara Collins.

Another way the command centre drives quality is by aggregating information that can predict what might happen to a patient. It provides a type of visibility above what the human eye can achieve alone. “Ideally, you’d want to know a patient is on their way to a cardiac arrest and intervene before the event actually happens,” Bak explains. The command centre uses algorithms that, with the collection of data such as vital signs and bloodwork, can give an early warning that a patient may have a cardiac arrest in the next few hours. This gives staff the opportunity to take pre-emptive measures and stop the attack from happening.

Another example is sepsis. In this instance, algorithms detect the potential for an infection to occur. Collins explains: “Sepsis is a blood infection, and we know that once a diagnosis of sepsis is made, the patient will do much better if antibiotics are given within 45 minutes of the diagnosis. So, we have a system now that will say ‘sepsis diagnosis, 30 minutes, antibiotic not yet administered, let’s intervene and get that antibiotic into the patient.’” Better outcomes like these, which translate into avoiding unnecessary care, not only benefit the patient, they contribute to increased capacity and reduced operating costs.

Says Bak: “What we were very strong proponents of, and we are absolute believers of, is if you drive quality care to a much, much higher level, you’re going to reap the benefits of efficiency, low cost and capacity—and all three of those things is what every hospital wants.”

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