The following is a condensed transcript of a panel discussion that took place at Tradeline’s Academic Medical and Health Science Centers 2013 Conference. The panelists are Ian McDermott, senior director of MedRIST, University Health Network, and Scott Kelsey, managing principal at CO Architects. The moderator is Derek Westfall, president of Tradeline.
Westfall: How are academic medical centers approaching the subject of alternative workspace strategies?
McDermott: It has more to do with our allied health individuals. At the University Health Network we have a group called Altum Health which provides rehabilitation services. Every member of that staff was handed an iPad. All of the electronic records—everything they do—is on an iPad; there is no paper, which means you no longer plan or program space for staff. All they get is a hoteling space, which delivers space savings but also makes for more interactive spaces.
Kelsey: In discussions with clients about officing and workplace strategies, the persistent question that comes up is, how do we think about clinical faculty offices? Often at an academic medical center, clinical faculty offices have very low utilization, and there are huge numbers of them. We just learned that the University of Kansas, at their academic medical center, has 500 clinical faculty offices and they have projected needs for an additional 200. That is 700 faculty offices. How do you rethink the nature of the clinical faculty office, and how do you move it from a four-walled environment that has low utilization to more of an open office strategy? I’d be curious what others are thinking about and have been undertaking on their campuses.
Barbara Welanetz, associate director, Facilities Planning Office, University of North Carolina School of Medicine: The UNC School of Medicine is connected to the state university and the UNC Healthcare System, physically and organizationally. I came from Mass General Hospital Partners Healthcare, where I was for 20 years. We have had some success in both places with traditional clinical faculty rethinking their workspace. We started with departments like radiology, anesthesiology, and emergency, where there is less direct argument for the need for private patient conversation space. But for those faculty who have administration and research duties, you do need to provide some kind of dedicated space. It is hard to fight that when you get arguments about recruitment. We work with the departments first that will think about exchanging some of the space for more lounges, better, more accommodating drop-in spaces, and either sharing or hoteling of offices. It has been easier to share offices than go to hoteling.
Westfall: Who else is doing some things with alternative officing or alternative workspaces?
McDermott: I would love to know of anybody who has been successful in convincing the academic or clinical program heads that they shouldn’t have offices, because I’d love to know how you did that without getting rid of them.
Lawrence Schnuck, senior principal, Kahler Slater: We were able to do it on one project, and we are no longer working on the campus!
Welanetz: We are seeing it more when adding new clinical-only, no-research staff with no administrative responsibilities; they are going to a hoteling or a drop-in workspace, especially if they are mostly working in some of the satellite offices. But that is about it.
Westfall: Who is planning or has just completed a new simulation center, and of what type, size, and capacity?
Kelsey: Our offices have programmed and planned about a dozen simulation and standardized patient skills training centers around the country, and we are probably only dealing with 30 or 40 percent of those that are being built. So I think it is a very active program that is being developed around the county and one that most health science education programs are deeply interested in. Our experience is that, on the low end, they are about 6,000 to 7,000 assignable square feet, and on the high end they are pushing 25,000 to 30,000 assignable square feet. It is really a function of the institution and how ambitious they are and what range of users they anticipate having within the facility.
Wes Drodge, project director, Memorial University of Newfoundland: We are just about to move in to a new faculty of medicine wing. In terms of simulation, as part of what we call the clinical learning development center, it is more than 15,000 sf, with an M.D. intake of about 80 per year (although we are sizing it for about 100). That is an important metric, in terms of sizing of a simulation suite. It also depends on how many other users you have: residents, nursing, pharmacy, or others. We have four quite large simulation rooms fully equipped, and two smaller ones. We have 20 standardized patient rooms, all double corridor, fully loaded, and about four major debrief rooms; a patient learning classroom, and a surgical skills OR, both real and simulated.
Robert Rawski Jr., regional program manager-Austin, University of Texas System: We are just getting under way with the planning of an education and administration building that is intended to eventually have simulation facilities. But we are simultaneously trying to understand what the needs are for the new medical school that we are building, in terms of interprofessional training, and also what regional needs there might be for simulation space, then trying to relate that to what is already available.
Westfall: So you are exploring regional partners and people who would want to use it?
Rawski: We are not that far yet, but I heard in one of the presentations that you have to be thinking about that.
Jo-ann Chubb, senior program manager, University of British Columbia: We are in the process of building six different sim centers in six different hospitals around the province. We have created a set of design guidelines so we have consistency in most spaces. They are all located within the hospitals, and they are a joint partnership between the health authorities, the ministry of health, and the University of British Columbia. Our biggest challenge is things like debriefing systems and looking at doing distributed debriefing. We run a distributed medical program, so all of our teaching spaces are connected. There are 130 rooms across the province. We are looking at a distributed model for recording and capturing information, so we are very interested in a cloud scenario and storage.
Westfall: How did you decide what the budget was going to be for your six sim centers, how big they were going to be, and their capabilities?
Chubb: We did a thorough needs assessment with our stakeholder groups and looked at how the space was going to be used, what the requirements were five or 10 years out, as far as we could anticipate. Like everybody else, we’re trying to design them to be as flexible as possible, and on the technology side, putting a lot of infrastructure in to accommodate future needs. There is a real interest in sim centers and so an appetite to spend money there. Where money is available, it is spent, and if not, it is planned for future development, so it has been a good position to be in.
Westfall: Are they all the same size?
Chubb: No, different sizes.
Welanetz: Just a funny little side note: There were about three or four different surgical specialty training simulation centers that are popping up because of beta testing with equipment. People are getting equipment, and then they are finding a space in their research lab or wherever, and then another surgical specialty decides to share with them. We are seeing a lot of this and I am just curious if anyone else is seeing that happen. It is causing us to say, hey, we need to sit down and figure out a more rational system of how this works, but there is nothing wrong with entrepreneurial startups, I guess.
Kelsey: We finished a large simulation and minimally invasive surgical training center at Methodist Hospital, an entire floor of resident training for the Cornell Weill School of Medicine. It had standardized patient and simulation and part task trainers, and then it had a large floor, a ballroom where they learned laparoscopic technique with live animal subjects. But there was a very interesting R&D core. The idea was that Methodist would create these kinds of incubator spaces and invite companies in to work on equipment. Then the surgeons from Methodist would train on that equipment and provide input. Obviously, to the extent that they are getting interesting commentary, they become very vested in the particular equipment of some manufacturer. I think that is a very interesting model. In some of the programs that (Jonathan Kanda) and I have been looking at in simulation, we are looking at creating these sort of Area 51 rooms where you can learn on equipment, and vendors can come in and develop partnerships with the institutions.
Drodge: We are starting to explore that for our new facility. We have had some discussions with some of the suppliers. We think that will be an important component of both the learning environment as well as the R&D.
Westfall: Much is being said about the visibility of M.D. programs. What is being done to build visibility for the other health professions?
McDermott: At UHN, we have a broad spectrum of hospitals. One of the things we have is a nursing program that cuts across all of the programs. They have dedicated areas for nursing education, and grand rounds for nursing. The same with allied health, which is also building specific programs.
Westfall: Is that what visibility means?
McDermott: To me, visibility is being able to give them an area that they have ownership over. Nurses make up the majority of our healthcare system. If they want to be more visible, then it needs to be somewhere they can congregate and focus on nursing skills.
Drodge: At Memorial University, we run four family practice clinics staffed by the family physicians of the faculty of medicine. Of course, we have interns and resident M.D.s, but we also have as part of those teams nurses, pharmacists, social workers, and we are now looking at bringing psychologists in.
Kelsy: Historically, many medical schools were integrated with an academic medical center, and they didn’t have their own building identity. There has been a push to build medical education and create that front door for schools of medicine. But what we are increasingly seeing is that it is no longer about the visibility of a silo—be it a school of medicine, nursing, public health, or pharmacy—but it is about an integrated front door and visibility for an interprofessional program. After all, you are training students together in order to treat patients in a team-based care model, so our view is that you need to collapse that all together and create a central, integrated vision of all of these programs together, as opposed to building upon a more singular model of identity.
Westfall: Is anything creative being done in campus master planning, and is that factoring into the integrated model?
Kelsey: I think there is in terms of programs and how you look at a master plan, benchmark it, think about the future, and how you want to create more of an integrated facility.
Westfall: When it comes to master planning, what is new? Who is doing something that is different or unique or leading edge, which is really adapting your campus to what it needs to be with a view to the future?
McDermott: We don’t take a site-specific approach to master planning. We have four hospitals as part of our network, but master planning is based more on programmatic themes. For example, we have oncology. One of our campuses focuses solely on oncology patient care, but that campus can’t deal with all of the implications of cancer care. So now you’ve got to look at what the other campuses could potentially provide in terms of services. If you did master planning for strictly one campus, you will lose the aspect of what is going to be best for the program. So when we are doing our master planning now, we are looking at all of the hospitals within it, even though they are physically different spaces, and doing it from a program need, not from a physical need. That is partly to do with the fact that we are in the downtown core of Toronto. There is no land to do anything with, so we have to figure out how we can make the best use of different campuses.
Westfall: Did the east campus also have its own distinct master plan?
McDermott: Two of the campuses have distinct master plans, but then they have to roll up into an overall one. The other two campuses, there is just no way to make them separately, so we did them together.
Chubb: We are going through curriculum renewal. That is going to have a big impact on how we change the way we teach. There are a lot of different planning streams going on. I am just triggering this process. I am trying to figure out how to bring those together and what is first, the chicken or the egg.
Welanetz: There are several themes that are changing the way master planning needs to be done. One is for the bigger healthcare systems when there was this huge growth. There was a lot of hospital-centric thinking at the beginning that threw off all the non-acute care to the satellites, and you leased space wherever you could. I am seeing in several big systems a consolidation of mid-level satellites now, bringing badly done leases into some critical mass of space. I think there is new thinking about how big some of those satellites should be and how they should relate to the mother ship. Then there is telemedicine, and what does that mean? Again, your comment about programmatic thinking. It is not just physical. How does that whole system work? Along with telemedicine on the university or academic side is the online learning. We are really interested in understanding what that is going to mean for campuses. I think probably the professional parts of the campus aren’t as affected, but we are all affected by online learning. How do you do master planning for that? Those are good questions to tackle for the future.
Westfall: What are the circumstances under which it makes sense to pursue third-party (private-industry) funds for campus building projects?
McDermott: That is where we said, okay, this isn’t strictly philanthropic, however, there are circumstances where it would make sense. For example, if IBM said they’d like to build the IBM "Center of the World on Computational Biology," but IBM wants to dictate what that computational biology would look like, I don’t think that would be appropriate. But if IBM wanted to partner with you to develop new technologies or new methodologies for dealing with computational biology, which is such a fast-growing field, I think there could be some way of doing that. You just have to be very clear about what the implications of accepting that sort of support would be.
Westfall: Poster child translational medicine programs that are really working, with results—are we too early for that or are there examples out there?
McDermott: What are demonstrable results? What were people asking for from that perspective? We have translational research projects that are changing the way cancer patients get direct delivery of radiation or direct intervention on surgical. We have combined in the same suite the latest in imaging technologies, surgical techniques, radiation delivery. In the time it took to move from imaging to delivery of radiation, they actually get that delivery. That is very different from the conventional way of doing it. That is translational research that has now moved directly into patient care. Is that successful? Absolutely. But how are we measuring it? I don’t know. We just know that it is better for the patient because it happens faster and it is more accurate.
Westfall: Are there any poster children out there? What do you think of when you think of translational medicine programs that are really working?
Rawski: It is interesting that there aren’t metrics that we are all driving towards. I think it just becomes the latest thing—well, you have to have one. I suppose the next stage would be to try to define or establish metrics to measure the success.
Westfall: What are the funding mechanisms for operations? Is overhead connected with research also connected to clinical environments?
McDermott: We just introduced a program at the University Health Network called ‘CAPCR,’ the Coordinated Approval Process for Clinical Research.
We did not understand the impact of clinical research and the cost to the organization. We know it affects many departments, everything from clinical laboratories to imaging to surgical suites, but we did not necessarily know what the effect was. So we put a process in place whereby anybody who wants to do clinical research now must complete a series of questions. It is mandatory because it is linked to what we call institutional authorization. They must complete a questionnaire that then creates “trigger questions,” which in turn create required internal authorizations. For example, one of the questions could be, “Would you be drawing blood from a patient?” If the answer is, “yes,” then that goes to the clinical laboratory and asks if they have the resources, are they aware of this, what would be the cost associated with that, and are you ready to provide approval to allow that to move forward? That makes sure that every clinical department is aware of what is going on and that they have a method for recovering those costs. Overhead is covering all of those different activities, but maybe it is a specialized medical diagnostic test that wouldn’t be covered in any way, shape, or form by overhead. Overhead is heating, lighting, security, finance kind of activities. It is not those specialized activities.
We have done it. Every department that gets noted in those trigger questions then has to provide an approval process to say yes, I’m aware of it, I know what the costs are, I have a method for recovering those costs. And then the vice president for research provides institutional authorization for them to conduct the work.
Westfall: And this is supposed to be some sort of an automated process?
McDermott: This is an automated process. It took us a long time. We developed the software internally and we call it “CAPCR.” I’ll tell you, we knew there was research going on. We knew there were implications within the organization. We just weren’t sure how to capture it. That’s how ‘CAPCR’ came up. It is amazing how much more we now know about what is going on and the costs associated with what is going on inside the organization. It has increased the workload for a huge number of people to actually review it, but we have a much better picture of the associated costs. It is really a big change.
Westfall: In their natural state, research, education, and clinical care are competitors for resources. What does it take to meld them together into a collaborative effort? This would be the space, staffing, financials, any kind of resources.
McDermott: It requires us to take it up to the CEO level. We have to bring together the heads of our education, research, and clinical care, and set priorities. Every different group will say their priority is number one. That’s fine, but then they have to have a discussion with the CEO. Once we agree on the priorities, we then set principles for how to move forward. But it is not an easy process, and it can take a long time to agree on how to move forward. I was hoping that other people might have different ways of doing it.
Kelsey: I can speak to the issue of sharing space. One of the trends that we are seeing is the interprofessional model. Above and beyond the benefits of patient care, they are doing it simply for the efficiencies of space. They are trying to get space utilization in the educational environments—in schools of nursing, medicine, pharmacy, or allied health programs—up over 50 percent, to 60 or 65 percent, perhaps even higher. Our research suggests that in that model of greater integration among those disciplines, you have a net savings of space. So ultimately that does come down to dollars and cents.
McDermott: I would agree with you in what we like to call the grey zone between strictly clinical care and research. But when you’ve got a requirement to increase wet laboratories and volume of outpatient patients going to clinics, where is the priority? Who sets that? Because there is no correlation between a wet lab activity and a patient coming in for clinical outpatient care.
Kelsey: It has been our experience when we are working on master plans and rethinking areas of the campus where research and education rub shoulders and compete for space, I’d say nine times out of 10, research wins because research generates money. The education is revenue neutral.
Westfall: This has to do with the way that people speak, the vocabulary we use when we are using new teaching paradigms and facility infrastructure for medical health science and allied health education. We’ve heard “interprofessional,” and “learning studio” to describe the environment. What are some of the other new words to describe what people are doing?
Jonathan Kanda, associate principal, CO Architects: You have probably heard a lot of the buzzwords at this conference. The usual one is “interprofessional.” We are always struggling to define what “interdisciplinary” truly means, or “trans-disciplinary” or “multidisciplinary.” In many regards, they are just semantics for what we think are essentially the same thing. I think we are looking for terms that address flexible and adaptable spaces. We are starting to look at words like “multi-modal,” which begin to suggest that there are different activities or modes that students, researchers, or clinicians engage in. Then we try to find spaces that can truly be multi-modal. It is not just a matter of whether this space can transform through moveable walls, but whether there is something innate, or an infrastructure difference in these multi-modal spaces. We have developed some concepts around what we are calling “skills lofts” as another term which is looking across functions. We’re no longer just thinking of spaces as “classrooms” or “simulation” or “anatomy,” and are now trying to find environments where we can merge some of those spaces that we still think of as mini-silos within a space program.
McDermott: I have a question that goes back to what Barbara was saying, and that is about electronic learning. How are we doing that, because we need to have physical spaces. We do have them where we are conducting webinars. We are conducting videoconferencing, and that is part of the learning paradigm. We are not relying strictly on a classroom anymore. How are we describing those spaces? Because they are not classrooms. I don’t think we’ve got a way to describe it so it is not being talked about.
