Commissioning the ideal perioperative suite: is going it alone your best option?
Healthcare building projects, no matter what the size, can be a complex and daunting undertaking. Whether it is a wonderful new greenfield site or a redevelopment of an existing facility, both require a great deal of planning, communication, time and money to ensure that the project finishes on time, on budget and as specified.
Healthcare providers are continually looking for technology which will give them a competitive edge and improve their facility's efficiency. Because of this and the rapid developments of technology, operating room (OR) design and fit out is changing rapidly. The integrated OR is here and with it comes a significant numbers of design options and related costs.
Post anaesthetic care units (PACU) and day surgery units are no longer just additions. They also have specific needs and equipment of their own, and the user groups within these departments are demanding a greater input into the design and fit out of their areas.
The risks associated with poor budget management, product selection and planning now take on a much more sinister look.
Every perioperative manager wants the best for their team and their patients, so does doing it in-house give you that option? Are you ready to help design, fit out and commission the ideal perioperative suite, or do you need to look outside your facility for assistance. This paper will endeavour to help perioperative managers through the maze and give them that win-win situation that they so desperately want when commissioning a new perioperative suite.
The project delivery process
There are generally five phases which are identified in a healthcare capital project delivery process. Kemper (2004) lists these phases as:
* Strategic plan
* Project launch
The breakdown of the phases is explained in Table 1.
Each phase within the healthcare capital project delivery process must be successfully completed before moving on to the next phase. It is the project manager (PM) who has the overall responsibility of ensuring that this happens. It is also their responsibility to assemble a team to assist them to plan, implement, monitor and control the courses of action through each of these phases. This team in turn has a professional responsibility to its stakeholders which may include the facility management, their clients and staff (PMI SC 2004).
The project team
The project team generally consists of personnel whom the PM and the major stakeholders believe will bring the necessary qualifications to the project which will ensure that the project achieves its goals and objectives (PMI SC 2004).
The personnel to be included in this team should consist of but is not limited to the following:
* Architect (schematic design plans)
* Perioperative manager/clinician
* Facilities manager
* CEO or other delegated hospital representative
* Project manager
* Infection control coordinator
* Engineer/biomedical personnel
* Occupational health and safety representative
* Sustainability management representative
* Accountants and administrators
* Medical equipment planners
[TABLE 1 OMITTED]
Communication between team members throughout the project is essential as a team that communicates well will mean less risk and will increase the chance of a successful outcome.
The role of the perioperative manager in the project team
As a member of the project team, the perioperative manager needs to ensure that they are familiar with both the project delivery process and their role in the project planning. This understanding should consist of but is not limited to knowing the answer to the following questions:
* What is the project?
* Who are the stakeholders?
* What is the budget?
* What is the completion date?
* What review process is to be used or could be adapted to the project?
* Do they have access to the required knowledge base to undertake their role in the project?
* Have the risk factors been reviewed and does a change and risk management plan exist (both problematic and technical)?
Knowing the answers to these questions will go a long way to ensuring that the perioperative manager will have the confidence to take control of their project role as well as being able to communicate the project goals and objectives to other team members and their staff.
The perioperative manager's role in the early design and development phases
During the early design and development phases of the project the perioperative manager will need to understand and develop a management plan for the areas of the project in which they will have a direct or indirect input. This plan is important to ensure that they are aware of the projects needs and required timelines during each phase. These areas of the project are (Schiavello Group 2008):
* Design consulting
* Inventory of existing equipment within your areas
* Move management and equipment life cycle reviews
* Equipment planning and budget analysis
* Equipment reviews and pre purchase assessments
* Equipment specifications and layouts
* Schedule development
* Procurement management and planning
* Milestone schedules for delivery and installation of equipment
* Warehouse and installation / relocation management
* Occupancy planning schedules
* Coordination of in-service education
* Product assessment
All of these areas are important components of the project. They must all be understood and managed to ensure that the project life cycle is kept on time, on budget and as specified.
How fast this process will be undertaken will depend on the size of the project and the building schedule. Communication within the team and the development of agreed schedules and responsibility matrices are essential to helping maintain a smooth process.
Do we have a volunteer?
It is not uncommon for perioperative managers to be seconded into a redevelopment project. In some cases they may not wish to be involved at the level that they have been asked, but it may be the only opportunity to ensure that their department is represented fairly in the building and procurement selection process. This opportunity should not be wasted otherwise those expected goals from the project may be unknowingly compromised.
It's too late to complain about the work environment once they start building. If any changes are made at this point they will come at a significant financial cost. As the budget has been well and truly fixed by this point in the project, this generally means unwanted compromise and no one truly wants that.
Architects need the clinical expertise of perioperative managers to help them understand care processes and clinical flows to help them avoid design mistakes which could affect clinical practice. When clinicians are given the opportunity to make an imprint on their work environment they shouldn't waste it.
It is an exciting thing to be involved in a project so plan for a successful outcome. Think about all the things needed. Do a risk assessment and address the points of risk. It's too late to say "if only" when the equipment starts turning up or you are behind schedule and over budget. It is well documented that as the project gets closer to the end, the cost of changes and correcting errors increases significantly (PMI SC 2004).
It is not a crime to ask for help if you are unsure. No one expects perioperative managers to know the answer to all the questions. Perioperative managers are clinicians not project managers. If you don't have the knowledge and time don't fake it!
It is also important for perioperative managers to stand up to the establishment when asked to undertake any role which puts an additional demand on their time, especially a redevelopment project. They certainly don't need the stress and burden of this on top of their existing clinical and/or managerial workload. Insist on time to do the work.
There are a lot of equipment and planning meetings to attend and research to be undertaken, as well as site visits and supplier meetings. These meetings take up a lot of time but perioperative managers need to attend them to ensure appropriate representation for the clinical team and to maintain their status as a valued member of the project team. (Berry 2008) stated that: "Clinicians have the ability to harmonise the design and fit out of any healthcare facility. They just need to believe they have something to offer the team"
Bringing an understanding of the care processes and clinical flows to the architectural team is vital and should be emphasised as early as possible in the project. This information can help avoid design and fit-out mistakes which will affect clinical practice. The walls and furnishing within your department should also not be neglected. The appearance of the clinical environment is just as important. If you don't have any input into the environmental design, colours schemes and textures you may end up with an environment which isn't conducive to staff and patient harmony. Kolston (2007) stated that: "When seen through a nurse's eyes, seemingly insignificant design decisions take on a new surprising weight".
One thing which historically has not been done well in healthcare capital works projects is the medical equipment budgeting (The Walsh Consulting Group Inc. 2008). There are many ways to come up with a budget figure but few seemed to involve engaging a professional medical equipment planner who has the skills and knowledge to understand clinical need, medical equipment planning, selection and the related budget management. Generally medical equipment budget comes out of the under funded and time pressed strategic planning or project launch phases. Perioperative managers will need to quickly get a handle on the department's furniture, fixtures and equipment needs (FF&E) so that they can cross reference them against the existing medical equipment budget allocation. Sometimes budget adjustments for FF&E can be made early in the project but the longer the project goes on the harder this will become. The Walsh Working Group (2008) lists the following budgeting tips as a guide to help you with your budget planning:
* Start early
* Establish funding guidelines
* Clarify owner and contractor budget responsibilities
* Involve departmental managers
* Develop documentation
* Include non-medical requirement
* Adjust for inflation
* Require budget adherence
Clinically based procurement
One of the project roles a perioperative manager will be asked to undertake is the equipment planning, selection and related design for the clinical area. This role has become considerably more complex and the time needed to do this well has grown significantly. One of the most common traps in this time crunching process is to either use historical or vendor driven purchase models. This is not to say that vendors should not be consulted. Vendors can be a very valuable asset to any healthcare project and their knowledge of their specialty equipment is both sound and up to date. They should however be regarded as a valuable resource and not the selector and decision maker of what you need. Historical purchasing might also be an easy way out, but will it give you access to new technology and best value for money? In summary, neither historical or vendor driven purchase models are good value, they generally mean missing out on future proofing technology, expensive over purchasing or both.
To help determine the new equipment requirements and the related budget for the perioperative suite, the perioperative manager must first undertake a concise life cycle review of the existing equipment within the unit. This is not just a case of 'does it work now?', but will it work and be suitable for use when your facility is commissioned. Overestimating a product's life cycle will cause despondency when staff should be enjoying their new workplace. At the same time, don't put items on the new equipment list just because someone is exerting pressuring on the team to replace them.
If unsure about the life cycle of a product, ask someone who knows about the product, such as the supplier. Having a concise existing and reuse equipment list will greatly help with the equipment budget management.
Sustainable equipment planning and procurement
Sustainable equipment planning (SEP) and procurement is in itself a major topic (Bielby 2008). It is important however to understand what SEP and procurement is, its benefits and why it is important to adopt SEP when making procurement selections. Depending on the size of the facility, the perioperative manager may or may not be directly responsible for the tendering or purchasing, but they will no doubt be involved in the tender/product review prior to selection.
There are some common principles, by which sustainable development is defined, as well as the processes needed to ensure that SEP and procurement can be achieved. Wikipedia (2008) outlines these principles as:
* Dealing transparently and systematically with risk, uncertainty and irreversibility
* Ensuring appropriate valuation, appreciation and restoration of nature
* Integration of environmental social, human and economical goals in policies and activities
* Equal opportunity and community participation/sustainable community
* Conservation of biodiversity and ecological integrity
* A commitment to best practice
* No net loss of human capital or natural capital
* The principles of continuous improvement
* The need for good governance
Considerable benefits can be obtained by effective equipment planning and procurement. The Environmental Protection Agency (EPA AHA 2002) lists these as:
* Reduce the ongoing costs and maintenance of equipment due to product efficiencies and increase life cycles
* Significantly reduce waste disposal and occupational health and safety costs related to equipment
* Provide a healthier and more user friendly work environment
* Be seen as a responsible environmentally caring facility
* Help to improve the impact on the overall quality of the environment
In all procurement practices there are hidden values in both energy and water conservation and one should never underestimate the financial savings impact that responsible SEP and procurement management can have on the bottom line.
The issues and risks--Is it time to call for help?
Perhaps it is time to remind the perioperative manager of several important things.
Even when things are not going well and they are feeling out of their depth, try not to panic. Don't lose faith in what is trying to be achieved. Talk to people about any problems which are causing concern, find a champion or liaise with the project team. This is when all the early work that was put into the team relationship building will pay off.
Most importantly, don't wait until it is too late to ask for help. Usually by the time the team realise that the equipment planning and its relationship to the overall project is much more complex than expected, things are generally not going well.
There has been many a conference in which healthcare providers have talked about their involvement in healthcare capital project planning. Nearly all spend a reasonable amount of time talking about the issues, what they have learnt from the experience and what they would do next time to have a better outcome. The truth is that there may not be a next time.
Redevelopment projects rarely happen more than once during a work employment cycle.
Questions to be asked are:
If a medical equipment planner (MEP) had been engaged to help would it have been an easier process?
Would it have been better to have had the perioperative manager assist them rather than endeavouring to manage the project internally?
Would it have been better to have had the perioperative manager as part of the user group, ensuring that they have input instead of being responsible for the risk management?
Is it reasonable to expect a perioperative manager to know about schematic, design development and constructions phases, architecturally significant equipment, installation time scheduling and to be able to read computer aided (or assisted) design drawings?
MEPs know all of this; they do it all the time. Why not use their knowledge and experience and enjoy the journey from conception through to commissioning and occupancy?
Equipment planners also give the project team a central focal point for all equipment-related issues, thus reducing the risks of duplicating the process. They also act as translators of information between the clinician, architects and builders: a chasm which is so often ignored or assumed not to exist.
Most people would agree that becoming involved in a healthcare capital works project can be an exciting prospect. However, internal management of the selection and procurement of medical equipment has become increasingly complicated, with increased technology and options available. Perioperative facilities are struggling to maintain clinical staffing levels, so is it right to remove clinicians from their valuable clinical role and second them into project teams when there are clear options available? Administrators need to look outside the institution for assistance in managing the FF&E and give up on the belief that they add extra cost to the project. Any medical equipment planner worth their salt will bring a value-adding service to the team. They reduce project risk, improve outcomes, remove the burden from the clinicians and will probably save you money as well.
Good luck with your future healthcare project.
Provenance and Peer review: Commissioned by the Editor; Peer reviewed.
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MHSM, BN, Cert Perioperative Nursing
Medical Equipment Planner/Clinical Consultant, Schiavello Hospital Solutions Pty Ltd, Southbank, VIC 3006, Australia.
Correspondence address: Schiavello Hospital Solutions Pty Ltd, 31-49 Queensbridge Street Southbank, VIC 3006, Australia. Email: email@example.com
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|Publication:||Journal of Perioperative Practice|
|Date:||May 1, 2009|
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