如果不是该项目实行实报实销（cost-based reimbursements），大部分CAHs都不能维持运营。它们位置偏远，人口稀少，无法按照医疗补助和医疗保险报销标准。它们无法像城市的医院一样靠着规模经济盈利，它们的患者数量少，按比例经营成本要更高。
如今医疗领域的新趋势对CAHs无疑是雪上加霜，迫使它们减少住院患者，引导患者转向更经济但收益更少的门诊治疗。在平价医疗法案的影响下，美国23个州做出的不扩大医疗补助的决定更加限制了这些小医院的预算。
另外，随着美国劳工部监察长办公室2013年提议出台，CAHs的项目要求变得更加严格，保证这些医院生存的机制岌岌可危。一些专家预测，到2020年，20%的CAHs将会关闭。
在这样严峻的形势下，CAHs亟需提高效率，探索更好的服务社区之路。其中，通过医院设计最大化运营效率，限制开支是医院的经济“健康”和当地人们健康的重要保障。
员工效率最大化
工资占据了医院预算的50%及以上，因此有效利用员工时间是改善CAHs的经济状况中极其关键的一环。间距更短的科室安排，共用的护士站，可以让护士在非忙碌时兼顾多个部门。西德尼地区医疗中心（Sidney Regional Medical Center ）护士长Julie Slagle表示, “我们设计新医院的原因之一就是要最优化员工效率。”
西德尼是内布拉斯加州一个7，000人的小镇，距离科罗拉多州首府丹佛大约三小时车程。一家25个床位的置换医院正在建设中，其设计的核心是增加效率，提高服务质量。
Slagle说，“老医院已经比较陈旧，而且过去增加了很多科室，导致有很多长走廊，行走距离太远，效率低下。”
新医院护士站设置在一个重要的中转位置，护士可以快速到达各个科室和病房。
效率的提高促进了医院的成长。Slagle说，“我们没有裁去任何一位全职员工。在提高医院效率的同时员工也得到了锻炼。服务质量提高了，患者数量也增长了。”
明年，医院计划增加两名内科医生，两名医师助理和一名全职外科医生。
另外，因为新医院设计中考虑了增长的可能，未来的扩建可以在不增加走廊的情况下完成。
设备维护自主化
乡村地区医院的设备维护充满挑战，特别是有时设备出现故障维修技师却在几小时路程外。Leo A Daly机械项目工程师Kim Cowman说，“根据这个情况，我们选择的设备尽量是医院员工能够自己维护的。”针对25个床位的CAH约克综合卫生保健服务 （York General Health Care Services）的机械系统，Cowman选择用空气冷却系统取代旧的水冷却系统，省去了水泵的使用，降低了系统的复杂程度。
意外来临时，乡村地区往往是最后得到救援的，所以CAHs的备用发电机需要特别重视。设计时要考虑“如果有暴风雨，油罐卡车多久能到达医院”。在多个实例中，Cowman推荐用更大的油箱。
约克虽然离林肯比较近，但是油罐卡车在暴风雨的情况下需要96个小时才能到。于是医院安装了4，000加仑容量的柴油机油箱，这是法规要求的四倍大。Leo A Daly电力项目工程师Doug Nelsen表示，这比较接近军队的标准。
“主要还是看这个地区的偏远程度，以及在极端气候或供电中断时能否在一定时间保证燃油供应。”他补充道。
例如，弗尔法克斯县有过局部停止供电的经历，于是工程师们为16个床位的CAH弗尔法克斯社区医院（Community Hospital Fairfax）选择了高瓦特发电机。
为西德尼地区医院选择锅炉时，Cowman选择了可以用燃料工作的。使用天然气的高效率锅炉平时可以节约能源，而作为备用，用天然气或燃油的标准效率锅炉在紧急情况下仍然可以工作。
至于控制系统，Cowman建议CAHs规划者考虑安装可以通过网络远程控制的。他解释道，“如果出现了故障，小镇却没有合格的技术，支持人员可以通过安全网站入口访问系统远程诊断问题，而不是仅靠电话来了解情况。”
门诊服务高效化
随着由住院向门诊转变的趋势，CAH设计不断努力提高门诊的效率。Leo A Daly高级建筑师Jonathan Fliege表示，“过去，放射室一般在医院内部，但如今我们会把它和公共区域连接起来。这样，门诊病人也可以方便地去到放射科。”
CAHs还通过共享设施提高运营效率。西德尼和弗尔法克斯医院都和附近的诊所共享设施，减少规模和运营费用。
如果想要更多节省开支的方法，设计时需要明确区分医院和诊所。
“医院有很高的安全标准，所以医院每平方米的医院的投入比诊所要高多了。考虑到乡村地区的紧急情况，比如乔普林的龙卷风，那么小镇需要一个安全性很高的医院。医院要根据法规来设计，当区分开医院和诊所后，医院门诊的部分就可以向更经济的标准看齐了。”Fliege说。
随着预防医疗的兴起，许多CAHs也包括了这个元素。西德尼和弗尔法克斯医院的会议室都可以供社区开展健康教育课。
患者体验优化
尽管
CAHs无需参与医疗补助和医疗保险报销的患者满意度评分，但是乡村医院管理者们仍然非常重视改善患者体验，因为他们认为这对于医院经营和社区关系都很重要。约克医院护士长Jenny Obermeier表示，“我们的目标是在改善患者体验同时保证他们的安全——达到私密，安静，减少跌倒风险。”
比如，因为翻新扩大后的病房到卫生间的路径清晰且障碍物少，患者跌倒的次数有明显的下降。另外，病房更加充沛的自然光和更宽阔的家庭区都有助于提高患者满意度。
适应为王
如今面临医疗行业的种种挑战，CAHs的存亡及其服务的社区健康都要求设计师和医院管理者重新审视那些既定的设计方法和操作流程。有时它们需要做出改变，或是将医院改造成最大化利用员工资源，或是重新设计来应对市场的挑战。虽然不易，但是好的设计会是最强的定心丸。
作者：John W. Andrews, Leo A Daly高级项目经理
翻译：肖腾芳
原文：
Designing More Efficient Critical Access Hospitals
http://www.healthcaredesignmagazine.com/article/designing-more-efficient-critical-access-hospitalsCritical Access Hospitals (CAHs) provide essential medical services to rural communities that otherwise would have little or no access to care. They’re part of a special class of Medicare hospital that, according to a 1997 law, must be at least 35 miles from any other hospital (or 15 miles in mountainous terrain), have 25 or fewer beds, offer a maximum stay of 96 hours, and have a 24-hour emergency room.
Without the program’s cost-based reimbursements, many of these hospitals wouldn’t be able to sustain operations. They’re simply too remote, and their populations too small, to function with standard Medicaid and Medicare reimbursements. They don’t benefit from the economies of scale that their urban counterparts do, their patient counts are lower, and their operational costs are higher by proportion.
To make matters worse, recent changes in healthcare have hit CAHs hard, creating pressure to reduce inpatient stays and drive patients toward less costly (and less profitable) outpatient care. The decision by 23 states not to expand Medicaid under the Affordable Care Act has strained the budgets of small hospitals in those states.
Furthermore, with the 2013 recommendation by the Office of the Inspector General that program requirements for CAHs be tightened, the designation that helps ensure the survival of these hospitals is under threat. Some experts now predict that 20 percent of these hospitals will close by the year 2020.
Because of these tough economic realities, it’s crucial that CAHs improve their efficiency and find better ways to serve their communities. Now more than ever, the financial health of CAHs and the health of the populations they serve depend on facility design that maximizes operational efficiency and reins in costs.
Maximizing staff efficiency with smart adjacencies
Payroll typically accounts for 50 percent or more of hospital budgets, so efficient use of staff time is a critical component of a CAH’s finances. Efficiency can be improved through designs that create smart adjacencies and shared nurses’ stations, which allow nurses to oversee multiple departments during less busy times.“One reason we designed our new facility the way we did is to optimize staffing,” says Julie Slagle, head of nursing at Sidney Regional Medical Center in Sidney, Neb.
Sidney is a town of 7,000 in the Nebraska panhandle, about three hours from Denver. A 25-bed replacement hospital is currently under construction there, the design of which will greatly increase efficiency and quality of care.
“The facility we’re in now is older and over the years has had a lot of departments added onto it. What ends up happening is, it becomes a lot of long hallways, a lot of walking space, and a lot of inefficiencies,” Slagle says.
“Let’s say I’m a nurse. A patient is being admitted, and I need to take him for an X-ray, labs, and then to his room. Right now, I’m going to have to walk down two hallways to get to admissions, get the patient, take the elevator down a floor, walk down the hallway to the lab, then back to the elevator, go up, and then walk directly back to the area above the lab, which is radiology, for an X-ray. Then it’s another 150 feet down a hallway to his room.”
The new design for Sidney places the nurses’ station at a critical node in the hospital’s circulation, giving nurses quick access to the inpatient, emergency, surgery, lab, pharmacy, radiology, and labor and delivery departments. “Everything’s right there,” Slagle says.
This increased efficiency is allowing Sidney to grow. “We’re actually not cutting [full-time equivalents]. At the same time that we’re building this facility for efficiencies, we’re also building staff,” she says. “As our services grow, our utilization of services grows.”
In the next year, Sidney will add two physicians, two physician assistants, and a full-time surgeon.
And because of how the design anticipates growth, any future expansions to Sidney will be completed without adding more hallways.
Making maintenance self-sufficient
Facility maintenance in rural areas can be challenging, too, especially when something breaks and qualified repair technicians are hours away. “We work around those limitations to select equipment that the staff is comfortable with maintaining. It’s best to include mechanical equipment they can maintain themselves,” says Kim Cowman, mechanical project engineer with Leo A Daly.When designing the mechanical system at York General Health Care Services, a 25-bed CAH about an hour west of Lincoln, Neb., Cowman specified an air-cooled system to replace the aging water-cooled system, thus eliminating pumps 泵and control complexity.
Backup generators for CAHs require extra design attention because in cases of emergency, rural areas are often the last to be helped. In several instances, Cowman has recommended larger-than-code-minimum fuel tanks. The key question guiding this decision: “How soon can a tanker truck 油罐卡车get to your facility if there’s a large storm?”
In York, despite relative proximity to Lincoln, the answer to that question was up to 96 hours. A 4,000-gallon diesel 柴油机tank was installed, which is quadruple the size that code requires. In fact, it’s closer to what military installations use, says Doug Nelsen, electrical project engineer at Leo A Daly.
“It came down to how remote the area was and not having a guarantee of fuel service being provided within that time should a large weather event or power outage occur,” he adds.
Similarly, a history of brownouts in Fairfax, Mo., with a population of 638, led engineers to specify a high-wattage generator for Community Hospital Fairfax, a 16-bed CAH.
When selecting a boiler for Sidney Regional, Cowman specified redundant boilers that allow flexibility of fuel sources. For example, a high-efficiency boiler running on natural gas provides energy savings during normal periods, and a backup, standard-efficiency boiler that can run on either natural gas or fuel oil provides heat in an emergency.
As for control systems, Cowman says planners of CAHs should consider installing one with remote Web access. “If something goes wrong and the town is too isolated for a qualified tech to be there in person, support staff can access the system through a secure Web-based portal and diagnose the problem remotely, instead of troubleshooting over the phone with the facilities staff.”
Catering to outpatients
As care shifts from inpatient to outpatient settings, CAH design is changing to improve outpatient access and efficiency.“More hospitals are using a front-door approach to planning radiology, lab, and pharmacy placement,” says Jonathan Fliege, senior architect with Leo A Daly. “Before, radiology might have been buried inside a hospital, but now we design them with storefront access to the public space. That way, your expenditure for a radiology room can easily be used for outpatients.”
CAHs are also increasing operational efficiency by sharing some facilities with clinics. In both Sidney and Fairfax, support spaces, dock services, environmental services, and laundry are shared with adjoined clinics, decreasing square-footage, up-front 预付 costs, and operational costs.
More cost savings are achieved by designing a clear and distinct break between hospital and clinical facilities.
“Hospitals are designed to an incredibly high safety standard, so every square foot of hospital costs much more than a square foot of clinic,” says Fliege. “If you think about an emergency in a rural community, like the tornado in Joplin, Mo., the town needs to congregate at the hospital for safety and medical care. The hospital needs to be designed to ‘institutional’ code, but by placing a fire wall between the clinical and hospital sides, the clinic side can be designed to less expensive ‘business’ standards.”
With an increased emphasis on preventive care, many CAHs also are being designed to include a wellness component. In Sidney and Fairfax, the public sides of the buildings feature meeting rooms that can be used by the community to hold health education classes.
Improving the patient experience
Although federal mandates tying Medicare and Medicaid reimbursement to outcomes and patient satisfaction scores do not apply to CAHs, rural hospital administrators place a high value on improving the patient experience, something that’s good for business and community relations.“In building our new wings, our goal was improved patient experience and safety—privacy, quietness, and reducing falls,” says Jenny Obermeier, head of nursing at York General Health Care Services.
For example, she’s seen a distinct drop in the number of patient falls thanks to updated and expanded patient rooms that provide clear paths to the bathroom and less clutter. Additionally, the rooms provide more natural light and family space, two things Obermeier says also contribute to patient satisfaction.
Adaptation is critical
In the face of today’s healthcare challenges, the survival of CAHs, and the health of the communities they serve, requires designers and hospital administrators to rethink entrenched design methodologies and operational procedures.In some cases, that means remodeling facilities to maximize use of staff resources and redesigning to meet the challenges of a changing healthcare market. Despite all the threats facing CAHs, good design can help the strong survive.
John W. Andrews, AIA, NCARB, is a vice president, senior project manager, and healthcare practice leader at international architecture, engineering, planning, and interior design firm Leo A Daly. He can be reached at JWAndrews@leoadaly.com. Jeff S. Monzu, AIA, NCARB, is a vice president and senior project manager at Leo A Daly. He can be reached at JSMonzu@leoadaly.com.
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