By Chad E. Beebe, AIA and Emma Oreskovic
From the June 2021 Issue
The definition of health care infrastructure is one that involves the individuals, facilities, and buildings required to deliver world-class health care. This complex term includes the components comprising basic hospital delivery of services, including both structural and maintenance of facilities. However, this definition is frequently defined according to the professional lens from which it is analyzed. The architect and engineer, for example, defines health care infrastructure as the buildings and systems used to provide health care services, whereas for a health care executive, health care infrastructure may be defined as the people and the process for delivering health care services. Ideally, health care infrastructure is an amalgam of each of these definitions, requiring the expertise of various professionals and the proper facilities and support systems to provide the care.
Maintaining existing facilities and acquiring newer technologies to provide patients and staff with an adequate hospital standard contribute just as much to the efficacy of the health care infrastructure as any of the aforementioned factors. However, the vital role facilities have in delivering proper health care is frequently overlooked and has ultimately become a major contributing factor burdening U.S. health care infrastructure. The issue at hand is that the C-Suite does not comprehend the gravity of their choice to defer maintenance, which will eventually result in nonsensical health care costs. Unfortunately, a recurring choice of the C-Suite is one that dismisses the vital role of upgrading existing hospital facilities. To avoid such misallocation of financial resources, it is important that the C-Suite does an adequate job of scrutinizing the materials needed to modernize and maintain the health care setting.
Although it is in the best interest of hospital occupants to be equipped with the latest technology, there are financial constraints which limit purchasing capacity. For this reason, investing in maintenance facilities frequently comes second place when competing against technology that is correlated with a direct return on investment (ROI). Investing in a Magnetic Resonance Imaging (MRI) unit, for example, takes precedence over maintenance facilities because of the marked ROI associated with it. Consequently, the MRI is prioritized over simpler maintenance of items like air-handling units (AHU) or boilers. It is only in the scenario where the AHU fails and the hospital is now at risk for cross contamination and surgical cancellations that the value of the AHU is recognized, its ROI incommensurably superseding that of the MRI.
Otherwise known as deferred maintenance, it is important to address the problem of stagnating hospital facilities, which, due to lack of funding, are becoming impossible to maintain. Budget constraints are acting as an impediment to providing patients and staff with adequate health care infrastructure. This problem contributes to the snowballing financial burden of U.S. health care. Today, Americans are dealing with a two-fold problem that included limited access to the latest technology and, exposed to the setbacks of deferred maintenance, an unreliable clinical setting.
Moreover, the extent to which the physical environment, and the facilities comprising it, contributes to creating an efficacious space for clinicians is overlooked. It is important to stress that the physical environment comprising the hospital setting is an extension of the clinical team. Much like the engineering team saves staff time and thereby improves outcomes, a favorable physical environment is likewise needed to effectuate optimal health care infrastructure.
The need for modernizing U.S. health care infrastructure becomes particularly evident when analyzing Age of Plant statistics. The AoP is not a direct measure of physical age; rather, it is a financial ratio that measures how well a hospital is keeping its facilities up-to-date. The ratio is calculated as accumulated depreciation over depreciation expense. As cited by The American Society for Health Care Engineering (ASHE), U.S. health care infrastructure is notably outdated, with the median age of health care plants for U.S. hospitals ranging around 8.4 years in 1994, almost 10 years in 2004, and 11 years in 2015. This trend shows it is getting worse, not better, and it is important facilities are maintained at a modernized level. Failure to do so may render infrastructure obsolete and be detrimental to hospital occupants and ultimately contribute to increased financial expenditure.
Allocating funds for maintenance facilities has become especially evident in the fight against COVID-19, which has demonstrated that there is no time to spare when clinicians are faced with an emergent situation. Knee-jerk purchases of UV lights, adjunct filtration systems, or even utilizing non-patient care space for surge patients all impact the health care physical environment and can add additional strain on the hospital’s ecosystem. Without proper engineering assessment prior to implementing these systems, they cannot be guaranteed to work as advertised, and in some cases, may negatively impact the space.
Due to regulations that are now over a decade old, facilities have been forced to continue employing outdated technology. To provide the best standard of care, state-of-the-art facilities are needed. Unfortunately, many facilities have fallen behind in technology due to outdated regulations. For instance, federal programs such as Medicare/Medicaid require hospitals to meet standards developed over a decade ago even though more current standards have been published. Standards in which guidance for surge, weather events, hostile events, and new technology were included in these federal programs. In quantifiable terms, U.S. health care facilities are approximately $391 billion dollars behind the acceptable standard of health care infrastructure. Put simply, this is the sum health care executives and policy makers should be investing into facilities.
Prioritizing facilities in need of change could substantially contribute to improving patient outcomes and infrastructure environment. Through predictive maintenance, or addressing maintenance issues before they surface in unpredictable and sometimes devastating ways, hospitals could avoid unnecessary costs associated with energy expenditure and spontaneous equipment malfunction, as well as the substantial costs associated with emergent clinical situations that may be interrupted by such malfunctions. By funding hospitals’ maintenance of facilities, the immense benefits would be appreciated immediately.
Beebe is Deputy Executive Director of the American Society for Health Care Engineering (ASHE), and Oreskovic is a medical student and global healthcare practitioner. ASHE is a professional membership group of the American Hospital Association. With more than 12,500 members, ASHE is the largest association devoted to professionals who design, build, maintain, and operate hospitals and other health care facilities.
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