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Building for the Future: The Role of Capital Planning in Smart Growth

By Matt Skoufalos

The weight of discussions about the acquisition of medical imaging equipment frequently is given over to questions of financing, budget cycles, clinical stakeholder interests and revenue. What may be further down the list of considerations, however, are details about the physical environment in which those devices will be housed and from within which they must function.

Robert Junk is the president and founding principal at RAD-Planning, a Kansas City, Missouri-based architectural firm that specializes in the design of imaging spaces. One of the aspects of capital planning that most commonly seems to surprise his clients is the brief life expectancy of the equipment they purchase, particularly in contrast to the much longer life of the building in which it’s housed.

“People always feel that when they buy a piece of equipment, they don’t have to worry about it for a long time,” Junk said. “Four years go by and they think, ‘Oh my gosh, I’m halfway through the useful life of this piece of equipment.’ One client has a dozen cath labs that are approaching ‘end of life’ at the same time, and they are realizing that they need to develop a phased replacement plan to keep the department operational.”

“Customers may have a piece of equipment that’s got a significant piece of useful life left, and they have to get a second piece of equipment that they haven’t planned for just to allow for increased patient demand,” he said. “When you’re dealing with technology, and as fast as technology changes, there’s planned obsolescence that comes into it.”

Junk said his firm endeavors to prepare its customers with a reasonable predicted equipment life span that’s informed by institutional plans about patient throughput and downtime between purchases, the better to prevent bottlenecks, scheduling concerns or delayed patient care. To craft that estimate, RAD-Planning relies on equipment utilization benchmarks developed for the U.S. Department of Veterans Affairs (VA).

“The VA looks at 80 percent of utilization as a piece of equipment being fully used,” Junk said. “By the time you factor in cancellations and the need to have some flexibility within your schedule, I think a lot of people find that is a low number. They then tend to run into scheduling difficulties, and they don’t have a lot of scheduling freedom in it. It tends to create some backlogs, essentially overbooking the machine.”

Other complications for equipment replacement include supply-chain issues – a lingering after-effect of the late stages of the novel coronavirus (COVID-19) pandemic – many of which are connected to the same shortage of semiconductors that has plagued the automotive industry. Similarly, other pandemic-related hurdles include staffing shortages that have affected every role from equipment maintenance to site planning.

“People only move at a certain speed,” Junk said. “We’ve had some projects delayed five or six weeks because the equipment vendors don’t have in-house staff to produce the documents.”

Another personnel wrinkle that arises less frequently in capital planning discussions is the degree of mobility among professionals in the C suite and other high-level positions at which decision-makers are employed. If the dominant voices behind a project or line of strategy change frequently enough, it can be difficult to bring a proposal across the finish line.

“We do a lot of work for some of the large, national hospital groups, and I’m constantly amazed at how much movement there is in the C suite,” Junk said. “Part of that gets into the budgeting side of how you keep capital improvements moving. As quickly as those roles change, I think it puts more pressure on individual radiology directors. We’ve learned over time that if we have a strong voice in the room that’s trying to drive in only one direction, and we can potentially see that that might lead to some issues, we’ll try to slow it down to allow other views and needs to be addressed.”

RAD-Planning Senior Vice President Tobias Gilk, who also operates Gilk Radiology Consultants of Kansas City, Missouri, said one of the most critical elements of designing a radiology room to satisfy the various needs of its planned users is developing a bespoke solution that exceeds the siting templates provided by medical imaging equipment manufacturers – the resources most frequently relied upon in the creation of medical imaging suites. Gilk became so familiar with these layouts that he could enter a space that had been emptied of imaging equipment and know for which device it was designed.

“It was endemic that architects would copy and paste the vendor-designed templates into their plans,” he said. “For anyone who wants to go down that route for speed, simplicity and cost – don’t. The vendor templates are fantastic for one explicit thing, and that’s to make sure that a site is designed with appropriate service clearances for the units. When a designer copies and pastes the templates for any design manufacturer, they are essentially ignoring codes, standards, accreditation requirements, and functional needs for the facility, which can be extremely detrimental to efficiency and throughput for the life of the facility.”

Gilk said equipment manufacturer guidance is based around supporting marketing that describes it as oriented towards the speed and quality of the study the individual scanner will perform. Those computational rates don’t, however, have much to do with how effectively patients can get into and out of scanners. He points out that the advertised throughput capacities aren’t reachable if the supporting environment – which might necessarily include changing rooms, space to establish IV contrast drips and more – don’t scale up with the allotted floor plan for speed and capability of the device itself.

“All those soft spaces wind up becoming the controlling factor for throughput and efficiency as scanners get faster and faster,” Gilk said. “For PET-CT today, you probably can get by with two uptake rooms based on the length of the study, but we actually build in a three-to-one ratio because the acquisition times for the imaging are getting much shorter, and it’s only a matter of time before you’re going to need the additional soft space to be able to maintain maximum efficiency in patient care and throughput for these accelerating scanners.”

The tension Gilk articulates is that between designing an imaging suite that will exceed the lifespan of the equipment in which it is housed by a factor of three or more. A more robust room configuration is one that acknowledges the routine turnover of capital equipment throughout the lifespan of the facility itself.

“Whatever you design the suite for, that piece of equipment’s going to get pulled out and replaced, and repeat until the technology’s obsolete, or the hospital gets moved to a different location,” Gilk said. “You run the risk of bulldozing all the capital dollars that might have been invested in the architecture and engineering of that suite because it doesn’t meet the minimums or the norms for the next piece of equipment.”

As frequently as the technology behind medical imaging equipment changes, Gilk noted that clinical utilization in radiology and imaging departments is changing twice as fast. Managers at sites that weren’t been designed to accommodate procedures like breast-guided MRI or interventional radiology may be confronted with the choice of retrofitting their existing facilities to adapt to changing levels of patient acuity, impairment and level of intervention. RAD-Planning measures its clients’ needs according to these levels. Class 1 designates an outpatient imaging physician’s office setting. Class 2 supports minimally invasive procedures. Class 3 is for image-guided surgeries.

“Before the architects, engineers, equipment and facility planners jump in doing the grocery-list count of ‘I need two CT and four MRI and six X-rays,’ some pre-emptive thought needs to be put into what specifically these spaces are going to be used for; what level of care and intervention,” Gilk said.

“If, today, you swear up and down you are positively a Class 1 imaging facility, and then a year from now you want to start doing image-guided biopsies, that’s a Class 2 function,” he said. “If you don’t have the requisite changes based on a higher level of uses, making those kinds of retrofitted adaptations can be destructive, disruptive and expensive. Make sure that the infrastructure is there to allow for higher use to allow yourself that future flexibility.”

“If you’re doing CT at a Level I trauma center, you’re going to have a patient conceivably on a vent requiring continuous clinical monitoring and supervision, and they may need medical gases or critical life support systems that require emergency power,” Gilk said. “The basic minimum criteria for designing a CT that’s going to support that level of care really should be different from the one that’s in a doctor’s office where they’re handling really healthy ambulatory patients.”

Architect Bryan Langlands, principal in the New York office of NBBJ, an architecture and design firm that specializes in health care work, encourages his clients to conceive of planning out an imaging suite as “future-predicting” rather than “future-proofing.” To him, the distinction is in admitting some margin of error and avoiding the inflexible thinking that accompanies such absolute statements. More critically, in design terms, flexibility comes down to architectural details like floor-to-floor heights, structural systems (Langlands prefers concrete to steel because it absorbs vibration more effectively) including column-free space, and designing robust mechanical systems to absorb the most complex patient cases that may arise.

“If you can have those three things, you’re aligning yourself to make changes in the future,” he said. “We have to be aware of over-designing the room trying to anticipate that they’ll be doing some procedures that they’re not doing today. When you start doing that, very quickly the costs go up, but you don’t want to have to renovate it because it was under-designed. It’s less about purchasing the equipment and more about the four walls around the equipment.”

One of the best ways to manage design constraints – other than modality clearance and footprint – is to consider designing a room that could possibly begin as a diagnostic suite and grow into a space that absorbs additional uses, including invasive procedures. This is particularly so in a hospital setting, Langlands said.

“What comes with it is sort of breaking down the fiefdoms,” he said. “E.P. likes to be in its own area, cath likes to be in its own area; these rooms are becoming hybrid-use rooms, and I think it’s benefiting the major hospital systems to put them in the same area ‘behind the red-line’ with the operating rooms. At large, academic medical centers, your case complexity is quite high. What I don’t see is how hospitals have figured out a way to run their machines on a second or third shift. They’re very expensive pieces of equipment to be sitting idle, only being used from 8 a.m. to 4 p.m.,” Langlands said.

Another critical consideration among design teams and capital planners at present is the overheated financial market. Project costs are climbing an estimated one percent monthly, which Langlands said makes “everybody really, really nervous.” And yet, NBBJ is fielding requests for proposals for “major new projects,” he said, which belies a health care market that anticipates the need to continue supporting the growth of its medical imaging lines of service. 

“I think what happened is, for the past two years of COVID, people didn’t build, and now with us coming out of it, projects are coming back,” Langlands said. “People are still very nervous about the cost, but they recognize that they need to get going, and get going fast. They’re worried about the unpredictability of the market. We saw a real slowdown in the past two years, but it seems to be coming back in 2022.” •

 

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