Check-in, exam, surgery, and recovery flows are likely to be forever changed as a result of COVID-19. But a larger concern might be how these routine patient flows have been silenced by the current pandemic. The lack of clear and accurate information on inventory and resources forced much of our healthcare system to suspend elective procedures and scale back other service lines in preparation for surge volumes which have not yet been realized. As an architectural firm often tasked with this level of inventory, assessment, documentation, and ultimately management of this information, we experienced this firsthand with different healthcare systems and architectural teams as part of the COVID-19 response.
Considerable effort has been put into documenting and understanding existing stock in order to repurpose and better manage this. However, our healthcare system is at a disadvantage because we lack a comprehensive, shared understanding of our assets and resources, and do not have a common, standardized language to track and share this information. Knowing what we have and standardizing the ways in which we communicate are essential to prepare for, and allow us to be flexible in response to, the next event.
When we get to the new normal, the COVID-19 pandemic will have redefined how we plan, design, and construct healthcare projects. What changes should we expect? Will the spaces and infrastructure of healthcare be significantly different than they are today?
The more likely and immediate changes that we will experience will be grounded in operations and communication.
Although nothing like the September 11, 2001 terrorist attacks, the pandemic is perfectly like these attacks in its unanticipated burden on our healthcare system. New York City’s Downtown Hospital, now the New York-Presbyterian Lower Manhattan Hospital, was located just four city blocks from the World Trade Center and served as a base site in the emergency response to the September 11 attacks. These events directly impacted changes that have since been made to the hospital. Renovations have been made to expand the decontamination facilities, increase and better outfit the trauma room to perform a wider range of procedures, and extend medical gases into the cafeteria to enable use as an expanded emergency space in the event of another disaster.
But Antonio Dajer, then Interim Chief of the Emergency Department, believes the changes coming out of the September 11 emergency response is less about built space and more about staff response and process.
“I think my big takeaway from 9/11, as far as medical staff dealing with an emergency, is that if you give trained doctors, nurses, physician assistants, nurse practitioners, and all medical providers clear direction and adequate resources, they will self-organize and do a very impressive job. The key is to have clear direction and a clear allocation of space and resources.”
This was evident at other New York City hospitals as well. For St. Vincent Hospital, staff in critical areas knew how to address surge capacities and which areas would be used for which purposes. But only a few key people had sufficient knowledge on where equipment and supplies were stored. This supports the need for disaster drills that now involve multiple areas within a hospital, conversion of space to critical care areas, and elements of chaos incorporated into the drills. The objective is to test resources, and the flexibility and creativity of the response team.
Another significant breakdown was in the communications between police, firefighters, and healthcare staff. This was not only a function of infrastructure that was destroyed but in the procedures in place for response to emergency events such as the attacks.
In times of emergency we want to answer questions. We want to make it better and fix things. We are emotional and reactionary. Doing something, offering a built solution and changing what we have, is an easy course to follow but reactionary, costly, and inflexible. This course of action is a response to a single event. As a healthcare community we need to be more proactive in understanding what we have and how this can be adapted to the events that we have not anticipated and tomorrow’s unknown needs.
Similar lessons have come from Hurricane Katrina in 2005, Hurricane Sandy in 2012, and the Joplin, Missouri Tornado in 2011. Each has strained the healthcare system and demanded a resilient response. In 2017, John Palmer wrote an article for Patient Safety & Quality Healthcare that addressed this, identifying specific lessons-learned from these tragedies that can result in better preparedness for the healthcare system moving forward. He speaks to value in communications, understanding resupply lines, knowing evacuation plans, and drills and preparedness.
“Emergency planning experts recommend that hospital staff train to communicate with each other and emergency responders using relatively primitive means, even pen and paper or two-way radios, in the event of a power outage. Also, federal and local officials now work together to plan. They go through the same disaster training and largely work from the same playbook, which means they speak a common language, use the same radio equipment, and can work together.”
Perhaps most importantly, Palmer offers advice that in times of emergency we know who our friends are to the extent of having “memorandums of understanding” in place with other facilities to sustain one another with patient care and supplies.
“You can’t always anticipate what your needs will be, but if you have partners you can count on, that will save the day in a big way,” says Paula Baker, president and CEO of Freeman Health System in Joplin, Missouri.
A common language to help us prepare is key. This unlocks our abilities to respond during emergencies and enables us to be resilient and adjust to changing needs. The other key – needs change. In times of crises we need to be able to adapt what we already have.
This starts with knowing what we have.
COVID-19 surge planning efforts brought to light the value in understanding our inventories and the means of standardizing the language of these inventories. We were actively involved with several healthcare systems and worked with many architectural firms in these planning, assessment and inventory efforts. We noted obvious differences in the way different healthcare systems track information, but also saw these differences within the individual healthcare systems themselves.
Policy has attempted to standardize alignment and the ways in which we communicate. Greater emphasis has been placed on joint response efforts and how different organizations are to work cooperatively. The Hospital Preparedness Program has enacted such policy to require greater alignment across response organizations through joint patient surge, mass fatality and evacuation planning, and promoted better relationships, joint exercises, and the sharing of information and resources.
What is lacking, however, is policy to address standardized asset tracking and documentation.
The values of standardizing what is known are what is expected – savings in time and cost, and improved accuracy in gathering and sharing information.
Accurate, standardized inventories and asset tracking is not novel, and at the core is a simple concept. BIM capabilities continue to pull us in the direction of fully developed, smart models. But even with these capabilities we need to be judicious and efficient in use of the tools.
The new normal will likely rely more upon our resiliency, and abilities to adapt the environments that we have. As with the current COVID-19 pandemic, September 11, and other natural disasters it is easy to look at an ideal built solution after the fact, but impossible to execute and implement this solution in real time when needed. We need operational flexibility and creativity, spaces that allow for this, and a shared knowledge of what we have and how it can be used.
Standardized asset tracking and documentation across different healthcare systems – a common language and open coordination – are at the core of this need. We need to be efficient and smarter with what we have.
The new normal starts with this.
Troy Steege, AIA
Vice President | Senior Project Manager Healthcare Team
Mr. Steege is a Wisconsin Licensed Architect, Senior Project Manager and Project Architect, specializing in healthcare project management, planning and design. His experience includes management of integrated project teams, fast-track delivery, and target value design, with a project focus upon healthcare campus master planning, hospitals, surgical and diagnostic centers, medical office buildings, and senior living facilities. Troy continues to push for development in the profession, with a focus upon research, and outreach opportunities to connect healthcare systems, industry, and academic programs. He has a proven record in developing and managing large scale, business critical design and construction projects.