Design standards: cutting the costs you can't see.

Nursing facilities have the power to maintain and improve aesthetic appeal without breaking their budgets - they just have to exercise it

* A nurse complains that her desk chair is causing back pain, so she goes home sick. The nursing home pays her sick time, plus must compensate the nurse who filled in.

* Several different departments separately solicit bids for carpeting within weeks of each other, duplicating tasks and missing out on a chance for a lower price with a larger order.

* Housekeeping removes stains from the lobby waiting area, resulting in a bleached spot as unsightly as the initial stain.

At first glance, these problems seem unrelated. In reality, they all result when a nursing home does not have interior design standards related to furniture procurement, architectural finishes and maintenance.

Nursing homes are in the middle of a massive re-engineering of all operations in an effort to contain costs. Re-engineering a nursing home's operations should include the development and implementation of interior design standards.

Design standards guide a facility manager or purchasing agent in planning, selecting, purchasing and arranging the products that affect image and function. The standards include manufacturer and model of furniture, fixtures and equipment such as desks, chairs, computer stands, window treatments and light fixtures, and floor and wall finishes appropriate for various applications. They also list the vendors and current prices and describe procedures for ordering.

Design standards ensure that the interior of a nursing home is coordinated, yet flexible. Typical standards will offer two or three options for each situation, so that end-users retain some selection while the institution is assured of a consistent image and purchasing policy.

Design standards can help to cut capital costs, reduce in-house personnel requirements and shrink the operating budget. Often, design standards pay for their development cost within a year.

Cost Cutting

The savings opportunities offered by design standards begin with planning. The facility can readily determine estimated costs of new furniture and equipment by referencing the design standards. The facility also generates accurate estimates when renovating a department by applying actual material costs to the project.

Furthermore, if a facility has design standards, it can negotiate with vendors for lower prices over longer terms in return for committing to the vendors' products. The vendors like being listed in the design standards because it is akin to having an exclusive sales arrangement with a facility. Vendors are quick to offer discount prices in return for steady, long-term business.

When McKeesport Hospital, located about 15 miles southeast of Pittsburgh, implemented design standards during a major renovation project, it found that vendors competed aggressively to get products listed in the design standards.

Also crucial to saving money in purchasing is truncation of the time-consuming bid process - developing specifications, soliciting prices, evaluating product and service quality and, finally, selecting a vendor. A design standard removes the need to constantly repeat these tasks, so the facility needs fewer employees to handle purchasing.

A facility with design standards solicits bids for products for numerous departments or for the entire facility, eliminating the duplication of effort that results when individual departments each go through a bidding process. Jefferson Hospital, located about 25 miles south of Pittsburgh, received price breaks and better service by approaching vendors with an entire year's worth of orders generated by the facility's design standards manuals.

McKeesport Hospital noticed that suppliers increased their inventory of products listed in the hospital's design standards manuals, which decreased lead time once an order was placed. McKeesport Hospital now finishes projects ahead of schedule, enabling renovated units to begin accepting patients and generating revenue earlier than anticipated.

In the design standards, facilities typically specify flexible products that fit into a broad range of environments. Flexibility prolongs product life and accommodates the "churn" that inevitably occurs. For example, a desk initially selected to have a computer return attached to its left side might be moved to another location where the computer return now must be attached to the right.

In addition to the cost savings, design standards result in:

* A more comfortable work environment: Employees function best in an environment in which they feel comfortable. Looking at the example of the nurse with the sore back, the nurse likely would be more productive had the purchaser of the back-breaking chairs balanced the importance of comfort and quality against the price. The consultant implementing design standards will study how the design of desks, chairs, computer stands and other equipment will improve employee well-being and enhance productivity.

* More uniform image: The consultant develops the standards into a facility's overall design scheme. The waiting-room furniture, wall protection, bedside chairs and window treatments are consistent within standards throughout the nursing home. In some facilities, even the room layouts are identical.

A better working environment for employees and more uniform aesthetics directly benefit patients. A nurse who is comfortable with her work environment responds more quickly when a patient calls for assistance. A consistent design allows patients to cope better when they are transferred from unit to unit during a recovery period. The location has appropriate furniture and accessories and similar, attractive finishes, which please the patient.

Implementing Design Standards

There are five steps a designer and facility manager use to implement design standards:

* Identify a core group to review selections and recommendations

* Determine appropriate products for each function and area

* Develop easy-to-follow design standards manuals

* Use the design standards manuals

* Update the design standards manuals

The Core Group

Typically, the nursing home works with a qualified, interior design consultant with experience in designing health care environments. To guide the design consultant, the nursing home must assemble a core group which provides requirements for each specialty area and describes the environment in which employees can best function. The core group breaks down the physical aspects of the facility into categories such as flooring, wallcovering, plastic, laminates, paint, chairs and window treatments. In discussing these aspects of their environment, the core group considers finances and function as well as appearance.

The core group usually includes representatives from maintenance and housekeeping, materials management, purchasing, and facilities management, as well as the nursing staff and administration. Rarely have so many departments been consulted in design decisions in most facilities, but it is necessary, because these are the individuals who can identify current product successes and failures.

Some facilities also have asked patients to help decide which beds and chairs are most comfortable.

Among the staff, housekeeping will protect against acquiring the cloth chairs that absorb medications or body fluids and the carpeting that retains stains. Likewise, a maintenance employee will object to an attractive light fixture that requires two workers 15 minutes just to change the bulb.

The core group can review past experiences and nail down the advantages and disadvantages of existing products and their applications. From there, the consultant develops and refines an overall scheme, integrating the existing with the new.

The Design Scheme

Each product is selected with specific uses in mind. Easily-mopped, nonslip tile covers the floor of an entrance corridor better than carpeting, which stains easily and soaks up water. The consultant, based upon input from the core group, decides what types of finishes should be located where.

The consultant works with the human resources department to pinpoint personnel levels, and function, style, price, performance and appearance are assigned for each supervisory level. Creating this functional hierarchy of interior design prevents a supervisor from having a bigger desk than the executive director, but also ensures that a secretary will have enough space for required equipment. Image and budgetary goals can be met facility-wide.

The core group can also help sell fellow employees on the benefits of the standards. Those who have helped develop the standards are the best resource for convincing other employees that there is no favoritism.

Developing the Manuals

The consultant creates design standards manuals with sections that address product categories, e.g., wallcoverings, window treatments, light fixtures, free-standing and systems furniture and seating. Some manuals include purchase orders specific for each product. A purchasing agent merely checks off what is needed and sends it along. Other facilities have the purchase orders on templates in their computer system.

Often, facilities develop multiple manuals that each cover broader areas such as clinical and nonclinical furniture or architectural finishes. Some facilities go further, developing maintenance manuals describing how to clean the products listed in the design standards. Other sections describe which replacement parts to use for specific repairs and where to order the parts. As with furniture, maintenance vendors offer low prices and prompt service in return for being listed in the manuals.

Using the Manuals

A facility manager leafs through the manuals, moving category by category to put a unit or office together, much like a puzzle. The design standards have already established the preliminary decisions, leaving only multiple-choice questions for a purchaser or end-user. If the target area calls for carpeting, the end-user selects from four or five samples chosen by the consultant and core group. The end-user cannot substitute carpeting if the design standard calls for floor tile, so costly mistakes are prevented and a consistent image is maintained.

Updating the Manuals

The design standards manuals can be used for a decade or longer, provided that they are periodically updated. A nursing home may find it can buy a chair that meets its requirements from another vendor at less cost. In some cases, a product listed in the design standards may be discontinued, so a new product must be selected.

With the pressure on all health care facilities during this age of reform, nursing home administrators are striving to cut costs while meeting the needs of patients. But even the most frugal managers see money wasted at their own facility through effort duplication, unnecessary compensation, and poor purchasing habits that directly relate to the facility's interior design.

A model program of standardized interior design can cut the waste. Design standards amount to "managed care" of a health care facility, allowing facility managers to control costs while keeping the facility aesthetically consistent and flexible, from the carpeting to the countertops, from the cafeteria to the administrators' offices.

Kathryn A. Jolley, ASID, is managing principal of DRS Interiors, Inc., a Pittsburgh-based design firm with extensive experience in health care interior design.