Healthcare Case Study: A Healthy Remedy

By Anne Cosgrove
From the May/June 2015 issue

Located in rural Dennison, OH, Trinity Hospital Twin City (THTC) is an integral healthcare provider in that community, serving about 35,000 people annually. In 2013, when hospital officials learned that they were in danger of losing their Centers for Medicare & Medicaid Services (CMS) coverage due to life safety concerns in the older portion of their facility, they expedited plans to ensure the imposed deadline for compliance would be met.

Trinity Medical Group area is one of the busiest areas at THTC.
Trinity Medical Group area is one of the busiest areas at THTC. (Photo: Ken Love Photography.)

Founded in 1912 as Twin City Hospital, THTC comprises two main buildings—the original structure and a 43,000 square foot addition opened in 2009. A critical access hospital, the 25 bed facility employs about 250 professionals who provide emergency, cardiopulmonary, imaging, and laboratory services as well as inpatient care, surgery and therapy. Meanwhile, THTC owns and operates a multi-specialty group physician practice that employs 16 providers across six locations.

Joseph Mitchell, RN, FACHE, president of the hospital, says, “The life safety issues were identified in the original building. We had already been discussing internally the proper way to address those concerns. So, what crystallized it for us was a Department of Health Medicare survey conducted at the hospital. As a result, it became clear to us what the issues were and the course of action we needed to take to ensure the building was safe for our patients and employees. And we undertook the process in earnest.”

One of the most immediate requirements was to install a sprinkler system within 60 days. Other life safety improvements performed during the six month project included fireproofing, fire alarm systems, updated electrical and plumbing systems, and ADA compliant components. Ultimately, the hospital retained its CMS coverage, completing the life safety improvements in Spring 2014.

In September 2014, THTC followed up that project with a second phase of facility upgrades—this one focused on aesthetic and functional improvements. Focused on the first and second floors, the renovation significantly improved the Trinity Medical Group space, the group physician practice owned and operated by THTC. Formal waiting room and registration areas were created for Trinity Medical Group, while waiting areas and exam rooms in the specialty clinic were also upgraded. In addition the hospital cafeteria, now the Stillwater Creek Café, was improved.

A Century Of History

A significant part of the surrounding community, THTC was founded in the early 20th century by a group of volunteer women who initially raised money to build a playground and later decided the need for a hospital was greater. A local reverend sold the committee the land for one dollar. The hospital board was officially incorporated in August 1915, and the original building opened in 1917.

Since then, the hospital has undergone many alterations and additions. In 2009, the most recent addition was a 43,000 square foot facility that connects to the original building, making a seamless transition between the old and new sections of this facility.

In 2010, that facility (still called Twin City Hospital) filed for bankruptcy, and in May 2011, Sylvania Franciscan Health (SFH), the health and human service ministry of the Sisters of St. Francis of Sylvania, Ohio (now a part of Catholic Health Initiatives (CHI)), purchased the hospital. At that point, the facility was renamed Trinity Hospital Twin City, and since then leadership has focused on continually improving the facility for the community.

In September 2014, SFH and CHI signed a definitive agreement to transfer sponsorship of SFH from the Sisters of St. Francis of Sylvania, Ohio, to CHI. Earlier that year, the two organizations had entered into formal discussions to bring together their two systems that have similar missions, values, and histories of care. Under the terms of the definitive agreement, CHI became the sole sponsor of SFH, which includes four systems throughout surrounding states.

When announcing this move, SFH spokespeople noted that the decision to transfer sponsorship of SFH was recognition that the healthcare industry is rapidly changing and faces a new model—one in which organizations are expected to offer integrated systems of care for specific geographical populations. As a result, many smaller health systems are joining larger systems in order to expand their care within existing regions.

At the time, Jim Pope, CEO of SFH, said, “CHI and SFH are well aligned in our missions and values, making this partnership one that brings together two very strong, complementary organizations. Through our combined skills and geographic reach, we will be able to bring new services to our communities.”

Critical Project Planning

With a tight timeline and budget limitation at the forefront for the THTC life safety project in 2013, it was especially important to Mitchell and facility director, Lora Morrow, to hire a general contractor familiar with life safety upgrades in a healthcare setting. Ultimately, the hospital chose Welty Building Company, a construction firm with three locations in Ohio and one in Houston, TX. As Mitchell explains, “One of the principals in our organization had experience with Welty. It was clear from our meetings with them that they had the expertise to manage this process for us in a way that was both expeditious and met our budget expectations.”CaseStudy-InsideArticle1

Bruce Wilson, director of construction with Welty, says, “After the initial meeting we identified the violations that needed to be corrected immediately to bring the hospital up to CMS standards. I then brought in Caplea Studio Architects [of Uniontown, OH] to join the project; they specialize in assessing the fire protection hospitals need to meet CMS standards.”

Commenting on Caplea’s involvement, Mitchell says, “They have granular expertise on life safety in healthcare. They crafted comprehensive solutions, so we could address the concerns in a way that was also budget conscious. From there, we put together the plan and executed it fairly quickly.”

Welty’s experience working in healthcare setting, coupled with the firm’s strong focus on lean construction, is credited with getting the project done expeditiously. Explains Wilson, “As part of our focus on lean construction, we do a lot of pull planning. This is a scheduling system in which we look at the end date that must be met, and we back it up from there to ensure the project is completed in that timeframe. It identifies everything that has to be done in a short time period. In this project, we worked two or three shifts most days to meet their deadline.”

A specific instance demonstrating the effectiveness of this approach was the upgrade of a tenant space on the third floor of the hospital. The nature of the care provided by there mandated the facility could not be closed for more than seven days—for work that would normally be expected to require about six weeks to complete. By compressing the schedule, and bringing in tradespeople virtually around the clock, the team met the deadline. The project involved removing ceilings, fireproofing those spaces, and installing new ceilings and lighting fixtures.

Working In An Occupied Facility

The hospital remained open throughout the upgrades, which spanned from September 2013 to March 2014. As facility director, Morrow worked closely with the Welty team to maintain the timeline, while taking care to keep patient and provider safety and comfort top of mind. “As we were getting ready to go into another area, the Welty representative and I would plan out what day they’d go in and when we needed to be out,” she recounts. “We’d move equipment and people out. The communication about timelines and who was doing what was very important.”

The hospital’s cafeteria was completely renovated during the recent project.
The hospital’s cafeteria was completely renovated during the recent project. (Photo: Ken Love Photography.)

A prime focus was maintaining separation from patients and providers. Trained in ASHE and ICRA [Infection Control Risk Assessment], Wally Steele, the Welty superintendent on the project, ensured the areas under construction were isolated and that work was carried out in a manner that did not impact any other areas. “We worked very closely with the Lora, providing phasing schedules of select areas that we would be in and the duration of the construction,” he says. “She relocated the affected employees and gave us access to sections at a time. We’d go in, and seal up the space, barricade, and install signage. We worked the plan week by week, treating each area as its own construction site.”

Wilson notes, “[Because of their training], our superintendents understand secondary infection and how to contain a space.”

“Trinity is not a large hospital, but they are an important one to this community,” says John Hartman, Columbus group president at Welty. “They serve a high percentage of Medicare and Medicaid patients, so maintaining their CMS accreditation was critical for the facility to continue to operate. They needed to get up to code quickly and cost-effectively.”

There were also challenges associated with working inside a nearly 100 year old building. “The architectural plans can only tell you so much. Once you break down a wall, you encounter unexpected issues that aren’t necessarily in the budget,” explains Hartman.

Before the renovation, this convenient, centralized waiting room for The Medical Group and medical records department did not exist.
Before the renovation, this convenient, centralized waiting room for The Medical Group and medical records department did not exist. (Photo: Ken Love Photography.)

Steele adds, “Routing the sprinkler system piping was probably the biggest challenge. We replaced many plumbing lines and brought a plumber in once we identified the scope. Additionally, with a 100 year old construction, the masonry walls ranges in thickness (from 10″ up to 2′) depending on the level of the building, so there were unexpected scenarios in that regard also.”

Commenting on keeping the project on track and delivering the necessary results, Wilson, says, “A key factor was onboarding an architectural firm early on to identify all the life safety items that needed to be corrected. Additionally, the hospital now has a set of building drawings stamped by an architectural firm. They can produce these to CMS, the State Fire Marshal, or any other inspection entity. Also, in the event of future expansions, they now know exactly where everything is in their facility.”

Renovation Follows

With the life safety concerns addressed and the threat of losing CMS coverage quelled, the hospital team decided to move forward with a renovation of the building. This would not only improve functionality for all users of the facility, but also provide the opportunity to unify further the original building with the 2009 addition.

Says Mitchell, “As part of our discussions around life safety, we had done some master planning on how we wanted the hospital to look. As we proceeded through the life safety project, we understood the opportunity to follow it up with a renovation. And we were able to create some synergies in terms of being able to make improvements around this plan during the life safety improvements. For instance when we knocked down a wall during phase one, we didn’t put it back up knowing there would not be a wall there under the renovation plan.”

In 2009, Trinity Hospital Twin City built a new 43,000 square foot addition, which features the main entrance.
In 2009, Trinity Hospital Twin City built a new 43,000 square foot addition, which features the main entrance. (Photo: Trinity Hospital Twin City.)

Mitchell adds, “Our board leadership understood the opportunity and through ongoing dialogue during the life safety process, we presented the opportunity to improve the older building, and they agreed. It presented very good value for us.”

Morrow explains, “We added onto the specialty clinic area. We took over space and moved some walls and made that a suite. So this created a dedicated space, complete with waiting rooms for the clinic. We also added exam rooms, updated existing restrooms, and added another.”

The renovation built upon the hospital’s efforts to improve wayfinding and branding elements on its site. Since 2012, work had been focused on creating visual and aesthetic unity between the new building and original structure. A new logo was part of this, along with new wayfinding and thematic elements throughout the facility. Part of the vision of this endeavor has been “to provide a variety of products, services and practice areas all branded with the Trinity name. The brand will speak to a new standard in service and quality health care.” For this work, THTC hired Molly Miller Design.

A significant improvement involved reconfiguring the Trinity Medical Group space. When the hospital completed the 2009 building addition, that was moved to the space that previously served as the inpatient unit in the original building. As Morrow explains it, this was an awkward space. There was no sense of “arrival” for patients and visitors. And the overall flow of the space was disjointed. By expanding the hallway there and creating a bright, new waiting room, the function and aesthetics of the practice group has vastly improved.

Accreditation And Awards Attained

In February 2015, THTC announced it had earned The Joint Commission’s Gold Seal of Approval for Hospital Accreditation by demonstrating continuous compliance with its performance standards. For this, THTC and its Trinity Medical Group underwent an unannounced on-site survey in December 2014. During the review, a team of Joint Commission expert surveyors evaluated compliance with standards related to several areas, including emergency management, environment of care, infection prevention and control, leadership, and medication management. Surveyors also conducted on-site observations and interviews.

Intimately involved in the process, Morrow says, “For the accreditation process, the JHACO standards were changed from when we were last accredited. And while we may have passed several years ago, without the recent life safety improvements I don’t think we would have passed. I went to our sister hospital in Steubenville when they were going through their accreditation process and followed along the process so that I’d know what to expect.”

Corridor with seating lined up against the wall.
Photo: Ken Love Photography.

And, in January 2015, Studer Group recognized THTC as the recipient of its Healthcare Organization of the Month Award for January. Each month, consulting firm Studer Group recognizes a healthcare client that stands out from its peers. The award is based on real achievements in creating a culture of healthcare excellence resulting in greater patient satisfaction, higher employee retention, healthy financials, and improvements in quality of care.

Since beginning a partnership with Studer Group in 2012, THTC has experienced improvement in patient satisfaction ratings and in financial operations. The overall patient satisfaction rating of the hospital’s inpatient medical/surgical care unit improved from the 64th percentile in 2012 to the 97th percentile rating in 2014, and the overall patient satisfaction rating of outpatient care staff rose from the 74th percentile in 2012 to the 83rd percentile in 2014. The hospital also marked an estimated growth of 14.7% in total gross revenue.

Says Mitchell of the recognition, “We still have work to do toward meeting our goal of becoming a world-class healthcare organization, but this honor affirms that our efforts are making a positive impact,”

In reflecting on the project overall, Mitchell notes, “Even the small improvements we’ve made have made significant differences in our operations. Part of our master plan strategy is getting maximum impact from small improvements. And, the reconfiguration of the specialty clinic and those done in the medical group with the new waiting space added significant value for patients, providers, and staff.”

This article was based on interviews with Mitchell and Morrow and with Hartman, Steele, and Wilson.