"What do we nurses know about construction? I can't move a screwdriver," says Candace Smith, MPA, RN, of Unity Health System in Rochester, NY.
Yet, like many nurse leaders, Smith had to learn the construction ropes in sink or swim fashion. The vice president of nursing/patient care services has earned the hard hat that hangs in her office in honor of the ICU, ED, and other construction projects she has worked on. "I do know that when you build things, things need to come together, work needs to be accurate, and the paint needs to be perfect," she says. Smith and others share construction management tips.
The economic crisis has definitely put the brakes on the hospital construction boom. More than 50 percent of hospital CFO respondents report that their organizations are substantially cutting back or putting a hold on new construction expenditures (HFMA, The Financial Health of U.S. Hospitals and Health Systems, December 2008.)
Even so, many hospitals are finding it worth their while to proceed with construction projects that ensure patient safety, improve efficiency, increase capacity, or accommodate new patient care strategies. Nurses involved in these projects can anticipate a fine-tooth comb approach to financial management. Now more than ever, building projects must be completed on time and on budget--and the projects must deliver the envisioned benefits.
Maintain Top Control
Rita Turley, MS, RN, has worked on more than 15 building projects, first as a hospital CNO and now as a consultant. She offers a word of caution to all CNOs: "Any time there's building going on, and you're not at the table, there's a serious problem," she says.
Turley, a past AONE president, recalls one building project in which there had been little to no involvement from nursing. The patient care delivery model was not supported by the new facility, and the patient care staff had no idea how they were going to safely and efficiently do their jobs. Poor planning sabotaged the project's success, says Turley.
The most frequent problem, Turley finds, is that the top nursing official has been too hands-off. While nurse managers may be the best choice for planning workflow details and space configuration, a CNO who delegates all responsibilities for a construction project is making a mistake.
"There is a very high-level role for the nursing executive," says Turley. A CNO sees the global picture and how the building project relates to the hospital overall in a way that a nurse manager may not.
Compromise When Necessary
Smith says nurse leaders must invest time in building relationships with other members of the construction project team. All team members must understand each other's perspectives and know one another well enough that they have a high level of trust.
"As a nurse, I need to make sure that people understand that I'm not just focused on providing the Mercedes-Benz. I can absolutely meet people in the middle," she says. "And this project is not about 'my way.' It's about the best way."
As director for clinical facilities planning at Exempla Healthcare, a three-hospital system in Denver, Robin M. Schroeder, RN, MSN, is the top clinical leader overseeing construction of a $225 million new patient tower at one hospital and a replacement facility for the system's flagship hospital.
"Everyone brings different expertise to the table, and all that expertise is needed to make a project successful--from the people who do the laundry and clean the patient rooms all the way up to the CEO level," says Schroeder.
Staff who will use the new space-from nurses and dietitians to transporters and materials management staff-need to be involved in planning the configuration. They need to be consulted on how the space could be designed to improve efficiency and prevent potential safety issues. Also staff need time to figure out any workflow changes required in the new space before they move in.
Start the planning process as early as possible and seek input from many types of constituents. "Get the bedside staff and the department staff involved in the project very early on," says Schroeder. "I think it is important to include not just employees, but also volunteers, medical staff, patients, and families."
Special note: Make sure every project has physician champions. Physicians have many good ideas about efficiency healthcare delivery, says Smith. Plus, if a project proceeds without physician input, you will run the risk of having an extremely dissatisfied medical staff for years to come.
Give Yourself Time to Succeed
The planning for a building project needs to start at least 24 months before construction begins, says Smith. For major projects that require a state-issued certificate of need, make that 36 months. Changing things after plans are drawn up wrecks the schedule and ruins the budget.
The Exempla system plans its large construction projects in several distinct phases. Operational planning is the "big picture" phase, followed by program planning, which considers how staff members work and what they need to accomplish their work efficiently. The ideas put forth from staff, volunteers, and others are captured in program documents for the architects to use in schematic designs.
Learn What Others Know
A nurse leader who is asked to manage a construction project may not have been involved in the organization's strategic plan or master building plan. But knowledge of those big-picture plans is essential to avoid costly mistakes.
For example, Turley says, when a hospital pharmacy runs out of space, the construction assignment is to enlarge the pharmacy. How does the strategic plan and the master facility plan affect that assignment? Perhaps the health system's strategic plan is to increase the role that pharmacists play in patient care. Or the master facility plan may call for three new patient care floors to be built in the next two years. Both of those plans would directly affect the scope of the pharmacy project at hand.
If possible, Schroeder says, make time to visit other hospitals that have recently completed similar projects. With a replacement hospital on the drawing board, Exempla has sent staff members, physicians, and managers on site visits to various hospitals to collect photographs, ideas, and lessons learned.
Learn About the Contractor's Job
The more you know about building codes in your state the better, says Schroeder. Just as important: Learn about the American Institute of Architecture (AIA) guidelines for healthcare facilities (www.aia.org). Authorities in 42 states, the Joint Commission, and several federal agencies use the AIA guidelines when reviewing construction plans for healthcare facilities.
The knowledge may save time and money by heading off a costly mistake. More likely, the information will improve your grasp of the project details and the information you share with the clinical staff whose input you need.
"I'm not saying that you need to have the depth of knowledge that an architect does, but it really helps to know what things are being recommended versus what are actual standards, "says Schroeder.
Keep an Eye On the Details
Your nurses are going to work in the new space being built-and your patients will be struggling to heal in that space. Smith says that gives a nurse leader a tremendous responsibility for making sure the space has been designed to provide the best possible experience for patients and the healthcare team.
"I found myself many days walking over to the trailers where the construction managers were working, saying, 'What are you doing with these doors?'" she says.
Additional Resources on Healthcare Construction
Healthcare Construction Trends and Capital Implications , HFMA's Financing the Future III. Developed in partnership with GE Healthcare Financial Services.
Designing the 21st Century Hospital, Robert Wood Johnson Foundation.
Publication Date: Sunday, February 01, 2009