Systems need to be fixed to drive real efficiency in healthcare

Gold Coast Hospital hit the headlines last year as they rolled out their Patient Admission Prediction Tool mapping tool to predict the number of schoolies expected to hit the emergency department over summer week.

However, the benefits of the tool stretched beyond the school break with the CSIRO Australian e-Health Research Centre’s chief executive David Hansen saying* it could save Queensland hospitals up to $23 million per year through improved efficiency from being able to plan ahead with a good degree of accuracy.

The CSIRO Australian e-Health Research Centre developed the software together with Queensland Health, Griffith University and the Queensland University of Technology.

Ahead of his presentation at Workforce Efficiency in Healthcare, I recently caught up with James Lind, Former Director of Access and Patient Flow at the Gold Coast Hospital to see how tools like this fit into the bigger challenge in healthcare to drive efficiency. He explained that many hospitals are still just focusing on the individual targets rather than looking at the bigger picture.

“The hospital wasn’t performing as it should, particularly the emergency department which is why we looked to redesign in the first place.

“The predictor feature is actually just a tool which every other business uses, the accountability frameworks and the meeting structures that you integrate those tools into to get the desired behavioural results – that’s where we’ve done most of our work.

“Data is really the currency by which we argue. The interpretation is the tricky bit and the devil’s in the detail of what data is or isn’t measuring. Once you’ve got over those few hurdles, you can actually use the data powerfully to understand what the issues are.”

Impressively, the team at the GCH managed to reinforce the governance structure by securing the attendance of the CEO in a weekly operational meeting:

“The meetings are designed around using these tools so we’re able to reinforce the behaviours that need to occur. When you say it’s going to be here next week then something occurs as opposed to doesn’t occur. A lot of that comes down to accountability in governance frameworks. Having the CEO in the weekly operational meeting absolutely reinforces the governance structure. The CEO is going be made or broken by the targets, if they don’t make their targets then they’re going to be fired, so there’s a real need for them to be there too,” explained James.

There’s no doubt that the team has made some real progress:, in the two to three years since they’ve been fixing the system and following the data, there’s been a huge improvement in performance results. Last year the hospital finished within 1 per cent of the NEAT target set – quite an improvement considering Gold Coast Hospital was rated worst in the state just a couple of years ago.

Matching KPIs

A key part to the improvements has been developing a set of KPIs that encompasses the system as a whole, rather than individual figures. James broke down the key to successful measurement:

“If you say you’ve made your NEAT, NEST and budget – if you didn’t achieve another KPI it would be looked at as more of a misdemeanour, and some of them are actually contradictory.

“If you fix the system itself though, the KPIs will flow with the system. If you just try and fix a number it won’t work.

“KPIs have to be easily measurable, even ones that seem a bit trickier to measure. Take satisfaction as an example, sometimes you have to pick surrogates of that, (a surrogate of how an ED works could be the ‘did not wait’ (DNW) rate.) You’ve got to have a combination and look in different dimensions with quality indicators, performance indicators and time indicators.

“Hospitals are complex adaptive systems, if you change one variable all the others will change in turn. The problem is you never know whether it’s good or bad as all the variables aren’t always measured.”

Where next

James has now been seconded by another hospital to implement some of the work from the Gold Coast and insists there are key principles that can make a wholesale difference to efficiency:

“A lot of systems are very similar to each other. The mathematics shows that everything is uniquely the same although people will tell you they’re different, and therefore the problems and the solutions by and large have got the same sort of flavours to them, they’re in slightly different quantities and proportions, but they have the same similar makeup.

Many are still not fixing the systems – more just making a number and hoping it will all to go away.”

So where to from here? In one word, NEST. The team are currently going through their ‘myth busting’ stage, looking at the mathematics of the state to work out the simple things first. For example, long case V start case timing and Smart Scheduling.

*See more: http://www.brisbanetimes.com.au/queensland/using-new-hospital-toolies-to-help-gold-coast-schoolies-20131115-2xm64.html

Accelerated design for new hospital – check out how it’s done.

In the run-up to Health Facilities Design and Development conference, I wanted to explore some of the new case studies on the agenda.

One topic that really stood out is Jeffrey Williams’ presentation in his role as Director of Nursing at St John of God Midland Public and Private Hospitals, in particular the short time it took to get the project off the ground.

I caught up with Jeffrey recently when he gave me a sneak preview on some of the features of the new hospitals, key design innovations and a breakdown of the user group consultation process:

Project overview

Construction of the new 367-bed co-located public and private hospitals has reached 70 per cent, and is on target for a November 2015 opening.

With 307 beds, the public hospital will offer a wide range of services to the communities of Perth’s northern and eastern suburbs and the inner Wheatbelt, while the 60-bed integrated private hospital will offer the choice of private health care.

State and Commonwealth Governments have jointly invested $360 million in the public hospital project that will be operated by St John of God Health Care under a public private partnership agreement. The WA-based private health care operator is investing $70 million in the private hospital.

Fast facts

  • First major hospital facilities to be built in the Midland area in more than 50 years.
  • HASSELL architects and Brookfield Multiplex are the design and construction partners.
  • The public hospital will treat approximately 29,000 inpatients, 55,000 emergency patients and 89,000 outpatients in its first full year of operation.
  • The public hospital will provide an expanded range of services from those provided by Swan District Hospital free of charge to public patients.
  • There will be 367 beds in total – 307 public beds and 60 private beds.
  • The public hospital will have 50 per cent more beds than the Swan District Hospital.
  • More than 1,000 staff will be employed at the hospitals.
  • Easy access will be provided for pedestrians, vehicles, and public transport.
  • On-site parking will include 725 staff bays and 221 visitor bays.
  • Easy drop off and access to the emergency department will be provided.
  • Patients, visitors and the community will enjoy landscaped gardens, courtyards, public art and plazas.
  • The hospitals are being built on an eight-hectare site, four times the size of the Midland Oval.

Accelerated design

The State Government released its expression of interest in September 2010 seeking responses within five weeks.

Post EOI submission, St John of God Health Care continued to work closely with its partners Brookfield Multiplex and HASSELL to develop a design within the allocated budget while awaiting confirmation of our selection to tender for the request for proposal.

Thankfully St John of God Health Care was selected and had a short 20-week window in which to prepare and submit a response.

On 1 December 2011, St John of God Health Care was announced as the preferred tenderer and, following negotiations, signed a contract with the Western Australian Government on 14 June 2012.

During the negotiation phase, St John of God Health Care, Brookfield Multiplex and HASSELL worked closely with the State Government’s consultants to ensure that any major design issues were dealt with at a high level so that construction could start as soon as possible after contractual completion.

This preparation allowed St John of God Health Care to achieve the State Government’s goal of starting work within one month of satisfying the conditions precedent, in August 2012

User group design

While we completed the design very quickly, we could only establish the design user groups after the contract was signed. This led to a concurrent construction and user consultation process that meant we had to focus on those areas where we needed to finalise the design and start building first.

We began a four-step user group process, with each group running between 16 and 20 weeks.

At the first meeting, we presented the users with a schematic design. The architects and builders then took the users’ advice and presented the modified design at the second meeting. The third stage was detailed design when we presented drawings showing room elevations and the position of furniture and equipment. The fourth meeting was a presentation of the final detailed design and allowing the users a last opportunity to highlight any remaining issues.  The detailed design was then signed off ready for construction drawings to begin.

Taking the Emergency Department User Group as an example, the users told us that the waiting room was too small and so we adapted the design accordingly. This process allowed us to drill down into the operational detail by asking them their opinion on matters such as the number of cubicles and the department’s layout.

Accelerated construction

While the user group consultations were taking place, preparatory construction work, such as piling and pouring concrete for the floors got underway. We also made decisions such as the location of wet areas to enable holes to be drilled for the later installation of pipes and drainage.

In those early days, we included around 130 square metres of expansion space on each floor. This built-in flexibility meant that we were well prepared for short-and long term expansion and design changes.

Managing expectations

From the word go, we made it clear to the user groups that the construction budgets were fixed.

The WA Health Clinical Services Planning Framework was a useful tool as some things were a given and did not need to be included in the design discussion.

For example, we had already made sure that we had the right number of beds and could explain to the users that we were working with a 30-bed medical ward, a 24-bed short stay surgical unit, or a 12-bed intensive care unit.  We also knew that St John of God Midland Public Hospital was a Level 4 hospital for cardiology and a Level 1 hospital for intensive care.

We were therefore clear about what we were trying to achieve and this allowed the users to understand the clinical scope so they could focus on how the unit might work and how we could make workflow more efficient.

Innovation in design

We standardised all of the rooms that are common across multiple areas of the hospital. For example, a dirty utility and a clean utility have the same layout in all areas.

We will be using swipe access widely throughout the hospitals for security, including to high traffic areas such as emergency department and restricted areas such as drug rooms.

All patient bedroom ensuite rooms were manufactured offsite as ‘pods’ to a standard, including a standard bedroom pod and a mental health pod, and installed within a short timeframe. While this was cost neutral from a construction perspective, cost and time savings were achieved in the installation.

We decentralised our staff stations, meaning that most ward areas have two or three staff stations instead of one centralised staff station and so clinicians will be closer to their patients.

Finally, we designed to accommodate future expansion. When the State Government issued its proposal for a 307-bed public hospital, they said that the hospital must have the capability to expand to 464-beds by 2021.

The design accommodates expansion in several ways:

1. Intensive Care Unit and Coronary Care Unit

This 12-bed shared unit has six rooms configured for intensive care patients and six rooms configured for coronary care patients. The six coronary care rooms can quickly be converted to intensive care rooms as the required services are already in place and space exists in the adjacent area for 12 coronary care beds to be installed with minimal disruption.

2. Operating theatres suite

The operating theatres suite is designed to cater for the maximum 464-bed capacity with nine theatres and three procedure rooms. These are all of equal size and configuration meaning that the three procedure rooms can easily be converted into theatres, while the procedure rooms can be re-located to a nearby area of the hospital.

3. Private beds

The two 30-bed private wards have been integrated in such a way that when the State Government wants to expand the public hospital from 307 to 367 beds, these can easily be converted into public hospital beds and St John of God Health Care will build a stand-alone private hospital on a nearby site.

4. Additional wing

The expansion to 464-beds can be achieved by adding a new wing extending out from the existing ward block on the northern side of the hospital. Again, this is designed to be achieved with minimal disruption to existing hospital operations.

Lessons learnt

I have two roles and two sets of responsibilities on this project: the first is clinical design and the second is transition and operational readiness. I have learnt lessons across both of these areas.

It was challenging in terms of the limitations on which people within WA Health that we and the other tenderers were allowed not access during the bid preparations. If we were to go through the same process in the future, we would request earlier and wider access to key players in the public sector.

Secondly, we would focus on operational preparedness earlier. While we had a firm view of how we would run the hospital, we did not start working through this in earnest until after the building program started. If we had begun earlier, we would have benefited from additional preparation time.

However, all aspects of the project, including the partnership with WA Health and the North Metropolitan Health Service, in particular, have worked really well. In terms of construction and commissioning, everything is on budget and on track for opening in November 2015

Working in partnership

The traditional public private partnership means the State saves on design, construction and facility management, but continues to deliver the service. As our model also includes clinical services delivery, the State Government can achieve further efficiencies.

Overall, it has been a very positive process, with the focus now firmly on completing construction, operationalising our commissioning program and finalising the details of the patient transfer from the existing Swan District Hospital that will close when the new hospital opens.

Hear more from Jeffrey during his presentation at Health Facilities Design and Development Victoria.

Leaders need to step up to drive hospital efficiency

Health is the second largest area of government spend across Australia, and the forecasts aren’t looking great.

National costs are predicted to increase exponentially; at current rates Treasury estimates health expenditure to exceed the entire state and local government tax base by 2043.

It’s pretty clear something has to change; preventative measures are without doubt the best option, reducing the need for healthcare in the first place.

Beyond this, hospitals are the costliest element to Australia’s health system, taking up to 40 per cent of current health expenditure. With that in mind, the spotlight is well and truly on efficiency.

There’s currently a big focus on technology and the potential for increased patient predictions and improved flow. For example, in NSW hospitals have begun publishing real time queue data for emergency departments.

I wanted to explore the driving force behind these changes. As the largest employer in Australia, hospitals have a pretty significant resource at their fingertips that could drive some real change.

With a yearly increase of around 9 per cent in emergency patients, Dr Harvey Lander, Director of Medical Services at Hornsby Ku-ring-gai Health Service is no stranger to finding ways of being more efficient. Ultimately, ensuring people don’t stay in hospital longer than they need to.

Dr Lander has been working on a Clinical Engagement Strategy at Hornsby Hospital that drives mentoring and leadership, and it’s clearly working. He’s been driving a clinical engagement project at the hospital that increased NEAT targets by nearly 20 per cent year on year. He explained the role strong leadership has played:

“Many clinicians have inspired me over the years. Those who thrive on a sense of purpose and mastery of all facets of their profession. The most effective leaders can collaborate, coach, mentor and build superb teams.

“Such clinical champions are needed to affect transformational change. We need to work together to improve our relationships and collaborate to make a difference both for patients and staff.

“There’s a real potential to improve efficiencies throughout the whole process within a hospital. At the core of this change is the ability to get clinicians to the right places at the right time.

“I recently saw a need to improve our care locally, driving a collaborative approach across the whole hospital.”

The project began with a small group of clinicians at Hornsby Ku-ring-gai Health Service, developing a vision of where they wanted to go. The team, with the help of a clinical redesign team leader, developed a one pager to outline what they wanted to do. This was then used to test the project and seek feedback from others that would be involved:

“We shared and market tested with other clinicians whenever we could at clinician meetings and during VMO individual performance reviews. The intent was to make this process about involving our clinicians in a meaningful way, where our most important resource could generate ideas for improving the patient experience, care and outcomes.   We have also been conscious of involving the junior medical workforce, because they are often highlighted as a forgotten group.

“We want to create a positive culture to make things easier and better for our staff, beyond the targets and numbers everyone is used to seeing. We want our clinicians to see, feel and believe that we are supporting the work they do to provide the best patient care,” he said.

For widespread rollout to be effective, it’s safe to say there are a few obstacles. Anyone driving change will know to expect challenges. There are still large pools of people that don’t want to be a mentor. Identifying clinical champions who are willing to get involved and drive change can be challenging. It’s a matter of passion, time, volition and skills.

Dr Lander explained the key to success comes in finding the individuals that are committed, rather than focusing on the ones that aren’t:

“Our clinicians are becoming increasingly committed to driving change that’s going to make a real difference. It’s a tumbleweed effect. Supporting these individuals is vital. We try to acknowledge their ideas and act on them, and celebrate successes to make sure our staff feel valued. This can sometimes be as simple as a genuine ‘thank you’. It also means being approachable and available, recognising the effects system demands on staff, as well as the effects of reform fatigue and burnout.

“Making patients the centre of our collective action has aided us in finding a common purpose and helped inform everything we want to do. We have been encouraging clinical staff to find creative solutions that they can implement. This has encouraged clinical directors to drive a lot of important conversations, helping to set high expectations. We know that competition drives doctors; they want to be the best in their craft and won’t tolerate being left behind. We are fortunate to respect each of our roles – credibility is important. The importance of building, strengthening and even repairing relationships is integral to our improving success.”

Such an impressive increase in results has of course exposed other challenges along the way, including tension between the system and clinicians. But it has also ensured a deeper understanding of the clinician and honesty when looking at individual, collective and cultural differences to help meet expectations (both internally and externally). Dr Lander shared his seven key areas to driving success:

  • Be willing to be involved, and lead if you are so inclined;
  • Be open to inspiration and innovation, share your ideas as they are the most important;
  • Take time to understand your local culture and what drives your clinicians;
  • Be honest about where you are and what needs to be done;
  • Acknowledge any conflict and be ready to have the necessary courageous conversations, but be kind to your colleagues;
  • This is a journey, so have realistic timeframes for the change., It can take five to ten years to change a culture;
  • And look to learn from others in Australia and internationally.

Join Dr Harvey Lander during his presentation ‘Improving Patient Flow with Effective Management and Staff Engagement’ at Hospital Efficiency 2014 in July.

Healthcare planning for an uncertain future: Adaptability

It’s no secret demands placed on health facilities are constantly changing, which means the services provided need to be flexible.

So can you really plan and forecast the needs of the Australian population?

There are a few strands that emerged during the round table discussion recently held for Australian Healthcare Week 2014 . Stuart Moore (Epworth Healthcare) referred to the analytical information Epworth use during the development stages of projects and how this can help with mapping provisions: “We look at data in terms of trends in clinical areas of all sides, public and private, across Australia. We use this data to try to map out growth areas across Victoria (the market in which we operate). That information directly impacts the development projects for our existing sites. We also look at Greenfield opportunity sites in Geelong.

“That information is used alongside the figures we get from Government forecasting such as funding models etc.”

There’s a whole range of information available from the Government that can be incorporated into plans. Anna Morgan (Southern Health) uses information based on areas of growth to gain a better understanding of the timing for expected growth in particular areas when mapping out services.

“The growth catchment predictions impact decisions made in our area quite heavily. We have a lot of older established areas that we currently serve, but in the outer regions there are identified nominated growth areas. We have to understand what the time frames are for that growth so we can incorporate them into our plans.”

The fluctuating population growth rates and behaviour predictions of those people have certainly been a challenge for health facilities in the past.

Leonie Hobbs (Carramar Consulting) has first-hand experience in Queensland, where unexpected population growth led to a long term design predicament: “We closed many beds because we had huge facilities at the time. Then something happened that we weren’t expecting: we had a huge population influx. We hadn’t designed to manage that. That’s the dilemma we are still stuck with now. The population modelling was done correctly, it was the provision of services themselves that we got wrong – we were hearing people would use more ambulatory services and therefore need less bed days, but we still needed the beds.”

So how can we really predict population? Ultimately, modelling can never be exact, but the message is to use the data sources available to make the most informed decisions.

The workforce challenge

Of course, the adaptability challenge extends beyond the build of facilities to occupy surrounding communities; the service itself needs to be just as flexible.

Two themes tie into the debate: the provision of services themselves and the location.

Perhaps one of the most interesting pieces of research happening currently is in Queensland around contestability. Leonie explained: “With the potential of outsourcing public work, there’s becoming a trend in QLD, NSW and WA where we are seeing more of a ‘Fee for Service’ model provided by the private sector. This may be something on the landscape for the future.”

Time will tell how much of an impact outsourcing and contestability will have. Projections produced by HWA in the ’Health Workforce 2025’ report make it pretty clear that without major reform in the pattern of health service delivery, Australia faces huge shortfalls in the nursing and related workforce nationwide, and in the supply of general practice and many specialities outside inner metropolitan areas.

There are considerations that should be made during the design and development to start to tackle this challenge.

The first is around staff and the experience they have. If we make our facilities a better place to be, we’re more likely to retain staff. The roundtable participants discussed how the biggest asset to any facility is the people who work within it, they therefore need to also be at the centre of the design.

We looked at several examples, ranging from the layout of facilities to providing open spaces for staff to relax and research.

The second consideration is around how we’re providing the service itself and a question that was raised by Arch Fotheringham (Brookfield Multiplex): “Are we taking the person to the facility or the facility to the person?”

Location based health

As mentioned earlier, the Government growth reports are one tool for forecasting. Arch suggests that it’s important not to reduce options when providing services in these expanding areas: “It’s easy to say there’s a growth area but you need to look at how you get people out to where that facility is. A good example is if you look at the Western Melbourne area, where a large percentage travel to Central Melbourne for treatment because it’s not available in that area. It extends beyond buildings…”

Anna spoke of a recent project in Dandenong, where they experienced similar location issues. The team are in the process of building new and improved facilities at Dandenong Hospital to ensure continued access to the highest quality of care for the community.

The work redevelops a number of community and ambulatory care services provided in disparate locations, bringing them into one central precinct. It’s an approach that extends existing services rather than builds new ones.

“As we continue forward, we’re about to do master planning in a growth area to do a very similar thing to what we’ve done in Dandenong. It’s about community services, medical consulting, allied health consulting and referring back to our main bases in adjacent areas where the tertiary services are. Understand the services you already have, look at how you can build on them.”

We couldn’t look at location services without discussing at least part of the rural health challenge. We have an ageing population; a large number of people are retiring and moving out to more rural areas where there aren’t as many accessible sub-acute services. They currently have to gravitate back into the capitals.

The population will still also continue to be dispersed – inner city health facilities are run off their feet whilst rural facilities are much quieter and come with their own workforce challenges.

Australia can’t continue to be so metro-centric.

Leonie confirmed, “The models of care are changing rapidly. We design to a model of care and it quickly changes. Take cancer care: we used to bring patients in for treatment and get great outcomes and survival rates. We’re now seeing the day ambulatory oncology unit gets just as good outcomes. Another example is around physiotherapists. I’m consulting with a facility at the moment that has a strong Allied Health background, the whole structure needs to change as we’re now moving into therapy aids. There will be fewer physios and more aids, more groups and less individual spaces. I’m learning people will require less cube rooms and bigger group spaces. We have to be flexible enough to change models of care.”

Solutions need to be found and they’re expected to be driven through design innovations, extended workforce training and technology.

Next week we’ll cover ‘Part Two:  Funding’ or download the full report here: www.austhealthweek.com.au

[Exclusive interview] Building powerful partnerships at Queensland’s new Lady Cilento Children’s Hospital

The new 359-bed hospital will be the biggest public children’s hospital in Australia, and the central hub of an enhanced state-wide network of children’s health services.

The Lady Cilento Children’s Hospital merges staff and expertise of the Royal Children’s Hospital and the Mater Children’s Hospital

It is part of a $1.5 billion program of work, including an adjacent academic and research facility, the refurbished headquarters of the Children’s Hospital Foundation; land to accommodate families within the precinct; improved road access and a new Adolescent Drug and Alcohol Withdrawal Service building.

Developing Queensland Children’s Hospital has been no easy feat. The overarching challenge: bring together two old (but long-standing) children’s hospitals and win people’s hearts…

Ahead of their presentation at Australian Healthcare Week 2014 in March, I caught up with some of the people tasked with steering the project from concept to completion: Dr Peter Steer, Chief Executive, Children’s Hospital and Health Services, Bruce Wolfe, Project Director at the project’s architect, Conrad Gargett Lyons, and Tim Treby, Project Director for the managing contractor, Lend Lease.

Could you outline your involvement in the Lady Cilento Children’s Hospital and where your focus lies?

Peter Steer: I’m the Chief Executive of the Children’s Health Queensland Hospital and Health Service that will be running and managing the facility at the end of the day. I’ve been involved for five years now, and my focus is to ensure that we deliver a contemporary design that delivers against our vision and mission, which is a really patient- and family-focused healthcare service.

Bruce Wolfe: This was something of the ultimate architectural prize so, initially, my involvement was bidding on the project; then Master Planning and developing the building concept with the design team, health planners and client. In many ways my role involved managing the complex relationships on the project and that is my focus now as the building nears completion

Tim Treby: I have been involved in project for over 6 years, from commencement of the Master Planning phase as Building Consultant initially, and then as Managing Contractors representative.  I am responsible for delivering the building to meet the expectations of the client and the many other project stakeholders.

The success of the project relies heavily on effective collaboration and communication. What would you say is key to getting this right?

Peter Steer: The relationship between the principals on the project. We were very fortunate with the appointed architectural team and the managing contractor as those relationships are critical. The other critical communication issue in health is the quality of stakeholder engagement and, in particular, user group engagement.

We learned through the project that you can’t over-communicate in the context of these complex designs. The healthcare professionals using the facility feel very strongly about their services.   There’s a significant education element around that stakeholder and user group engagement. It was one of the things we got better at as the project progressed.

I’ve been involved in a number of significant projects before and am continually surprised at how difficult it is to bring people along. Some clinicians have strong opinions and their expectations are very high, and not always contextually appropriate for the capital build. There are real challenges in managing stakeholder user groups. We took the communication and listening process very seriously. We went back repeatedly to review and subsequently did some significant schematic re-design work because we were keen to ensure people felt listened to.

Bruce Wolfe: Time spent listening is always valuable; listening to both ideas and criticisms. It’s crucial to moving forward collectively.

Tim Treby: I agree that the success of any project relies heavily on effective collaboration and communication.  The larger and more complex the project, the more challenging this becomes, and the more important it is.  This project has been extremely challenging in virtually all aspects of the development process, and the toughest issues to overcome, in hindsight, have been those where communication and collaboration have been lacking in some form.  We are fortunate to have a client who recognises the importance of this and we are able to communicate openly and resolve potential issues early. 

What preconceptions did you bring to the project and were they reinforced or altered?

Peter Steer: My preconception was that it was going to be a very complex capital build and that there would be issues around our workforce merger, given that this was bringing two hospitals together.  They’ve been reinforced – it’s a very complex project that is now going well, I’m not sure there’s been anything like it in this country before.

Bruce Wolfe: At the interview for the project, we talked about a very different type of hospital, open and “permeable”. I actually wondered whether this may have been too big a move for Queensland Health but it the opposite was true, the client was keen to embrace innovation and bring new ideas to the planning including the concept of a more open and community connected hospital. The site was also challenging and involved a broad review and evaluation of the urban context. This was fundamental to the success of the project and in reality was every bit as complex as imagined.

Tim Treby: This was always going to be a technically challenging project; a heavily serviced hospital including an energy facility on brownfield site bounded by major arterial roads, bus tunnel, schools, hospitals, residences and a telephone exchange. Having been involved in many hospital developments before the LCCH this was understood, and has been reinforced many times over during the life of the project.   The project has traversed several cycles, including economic, political, industrial, corporate and stakeholders which have all had to be negotiated.  I knew that the project team would have to be tenacious to overcome the challenges that would and have come, and also that we would be all be justifiably proud of the end product.  It is a fantastic result.

QCH was not a public-private partnership. Do you see any benefit of using this new PPP style?

Peter Steer: We benefited from not being a PPP, primarily because the site was complex and had some major design challenges, along with the organisational merger; engagement was critical. And certainly the procurement process and the choice of managing contractor versus a PPP allows a lot more user and stakeholder engagement. That was the advantage for us.

In terms of Public-Private Partnership, given the challenges for government finding injections of capital money, PPPs will become more attractive. PPPs will be a mechanism (and not an unreasonable one) to deliver these big projects that otherwise will simply not get off the ground. PPPs certainly have their place and their advantages, but I don’t think there’s a perfect methodology. The mechanism of procurement really does need to fit the purpose and context.

Bruce Wolfe:  Shortly after the design of QCH, CGR won the commission to master plan and provide the design of the Reference Project of the Sunshine Coast University Hospital, a PPP project on a large scale. One of the difficulties in the PPP process is getting sufficient client and user-group contact with the competing design teams. I think that was well handled in that project but it remains a difficult aspect of PPPs. The benefits are in relation to the capital cost savings for government and allowing the health experts concentrate on delivering their core expertise.

Tim Treby: They appear to be desirable from a public funding point of view, however I think that the cost to industry to bid for PPP tenders is excessive and unsustainable.  There must be a more equitable procurement methodology that can be developed.  I would question whether they are sufficiently client focussed for particularly complex projects.

How is the project responding to a change in customer demands?

Peter Steer: Things have changed enormously over the last seven years.  To be both accurate and give praise where it’s due, the architects in their design have designed a facility that maximises flexibility.

As our understanding of service models has matured, we have had to make changes. We’ve obviously had to draw a line in the sand, but we were fortunate with a flexible design in the first place that has allowed us to survive well with adaptation over that long period of time between design and delivery.

Bruce Wolfe:  Our customer for QCH was Queensland Health. In the long delivery of such a project there are inevitably changes in their demands that impact on planning. The versatility and flexibility of the design was tested during that six year period from master planning to completion.

Tim Treby:  I think that when the Hospital opens people will be impressed with this building.  It is a facility that has the welfare of its young patients and their families firmly in mind, as well as the needs of staff and visitors.  There has been future flexibility built in, and much work done by the client, design and contractors teams to ensure the latest technology is provided in the facility, considering the lead times which have had to be managed.

What have been some of the biggest challenges you faced throughout the development of the project? Are there any lessons learnt?

Peter Steer: It’s critical in any healthcare design, particularly given the context of our merger and bringing two organisations into one, to get that engagement right. The other opportunity is getting stakeholders to understand there may be design solutions and technology solutions to some of our service delivery challenges at the moment.

A classic example of such an opportunity was in our outpatient design – we had our clinicians absolutely horrified that there was very little waiting space within this hospital for clinics etc. When you think about it, at first, a patient might think, why don’t we have larger waiting areas? But, the principle about being patient- and family-centric with this children’s health service is not to have people wait, and to design a facility that would enable waiting makes no sense.

You can create tension by your design, your intent and your vision for the organisation, and through technology, make a real difference to a design solution. There’s a major change agenda, a service change opportunity, with these big design projects, it’s difficult to grab them.

The other challenge is that on a really big, long project, the team changes. You have changes in personnel, particularly in the public sector, in the bureaucracy with whom you’re interfacing, and often have government changes. Managing that change can be a challenge.

Bruce Wolfe:  This was a complex and testing project and there were really no areas that were not a challenge.  A difficult brown-field site, two separate and very different organisations coming together, a highly visible project politically and a turnover of client project directors during the course of the project. The challenge was to stay focussed on the architecture and the building and the problems that were in a domain where we could be most effective.

Tim Treby:  As I have already mentioned there has been no shortage of challenges on the project.  The site location provided many technical and logistic challenges, and the form of the building required a lot of planning to develop methodologies to safely construct it, and it did drive innovation.

The clarity and alignment of expectations for the user group approval of the developed design was challenging, and exacerbated by external criticism and lack of continuity of some participants.   The importance of external stakeholder engagement was recognised and managed well.

There has already been a lot of interest in this project from a design perspective. What has been your impression from that commentary?

Peter Steer: This project (and certainly the design that’s put on the table) is centred on creating a green and healing environment.

This vision has permeated everything with extraordinary attention in design, designing to minimise use of electricity, having our atria and major thoroughfares in the hospital, open to the environment.

There’s also a community vision where the intent of the architects has lived true, they’ve ensured the hospital is open to the community. There are major ‘windows’ that allow people both to see in and see out from this facility, which not only helps with finding context about time of day and place, space and time, but also builds community connections. For a children’s hospital, this is critical.

Bruce Wolfe:  The building occupies the site quite powerfully which has generated discussion both for and against. As the building is revealed, the gestures of opening the building façade and connecting the inside spaces to the outside is more apparent and helps in the scale of what is a very large building. There is more of the ground plane also given to the public.

We have been pleased with the comments as the scaffolding has come down and surrounding buildings removed to reveal the civic domain.

It was also pleasing to be the first Australian hospital to win the Academy of Design and Health Award for Best Future Hospital

Once it’s open and people get to experience it, as opposed to looking at pictures, I am sure the impact will be much, much more significant.

Tim Treby: The external appearance tends to be polarising, and it certainly has people talking.  The finished product being delivered is true to the brief and design intent, and will provide fantastic facilities.

The project has clearly seen lots of innovation. Have you any examples of how it’s acted as a catalyst for change for other hospitals?

Peter Steer: There’s little doubt that our emphasis on service planning and patient flow as a result of this process is influencing ambulatory care delivery across Queensland. We’ve been innovative in terms of our ambulatory clinic not just design, but service. We’ve got some great feedback and interest from health services across the State. It’s that interface between service design informing building design that has been the advantage.

Bruce Wolfe: I think it is probably too soon to tell but I think that since the design of this building was revealed in early 2008, there is a renewed emphasis in hospitals on intuitive way finding and creating public spaces in the building that link to form a network of volumes rather than of corridors and passageways. There have been planning innovations as well but these would be tested in practice before being adopted more broadly.

Tim Treby: The have been many innovations implemented during the construction phase, which will no doubt be used on future projects.

Hear more from Peter Steer, Bruce Wolfe and Tim Treby during their exclusive presentation at Australian Healthcare Week:  ‘Queensland Children’s Hospital: The New Look PPP’s: Powerful Precinct Partnerships’ This project case will focus on the new Children’s Hospital Project, demonstrating a strong collaborative process adopted by the client, architect and contractor which has ultimately acted as a catalyst for change

Designing health facilities of the future: the big debate..

It’s been a big year for healthcare facilities design in Australia. Kempsey, Blacktown Mt Druitt, and Gold Coast Private Hospitals have seen significant developments over the course of 2013 and the VCCC, Royal Darwin and Fiona Stanley in Perth are just some of the big players making advances in design.

Over the last 12 months, I’ve been lucky enough to interview some of the key players in health facilities design, management and construction – those directly involved in projects that are shaping our healthcare facilities for the future.

As the Australian demographics change, so do the needs of the patients, staff and visitors who require health services. Maximising the potential of a limited budget is becoming much harder and customer centricity is becoming more important than ever to improve outcomes.

It seems pretty clear there are still some key underlying challenges that remain in the industry; whether planning, expanding, building, maintaining or retrofitting a health facility. The growing population and tightening funding is central to the need for continuous innovation.

There are also some huge opportunities that have been gathering pace over the last 12 months, opening up a whole new realm of possibility for innovation in design, sustainability and technology, to name just a few.

To get a clearer picture of what’s changing the landscape of future healthcare facilities, ahead of Australian Healthcare Week 2014 we brought together eight of the industry’s key players, already heavily involved in driving sustainable facilities for the future and asked– how can Australia plan effectively for an uncertain future?

It’s no secret that I’ve always enjoyed working on our healthcare events, so was pretty excited to have everyone in the same room sharing ideas for the future.

As a result, I’ve drawn up this report on some of the key trends that emerged: Australian Healthcare Facilities: Planning for an uncertain future.

It was my first venture into the report writing field, but with so many interesting conversations throughout the expert roundtable it seemed the logical thing to do! Hope you find it interesting, looking forward to AHW 2014!