Hear from the Experts: Rural Hospital Design Q&A

Wednesday, February 20, 2019
Image: surgeons running through a hallway

Critical access hospitals (CAHs), often called rural hospitals, provide care to 20 percent of the U.S. population. However, very little research reviews the appropriate sizing of CAHs and the effect CAHs have on patient outcomes.

A team of three rural health care experts is currently engaged in a study that will benchmark the physical characterstics of 15 CAHs across different regions in the United States with best practice prototypes and current Facility Guidelines Institute Guidelines. The goal of the study is to understand the unique challenges that rural health care facilities face while identifying trends, key spatial characteristics, and CAH design strategies. The hope is that the study’s findings will be used to influence future regulatory approaches for this distinct facility type.

The team includes:

  • Hui Cai, PhD, assistant professor, University of Kansas
  • Rebecca Lewis, FAIA, FACHA, CID, principal and director of healthcare design, DSGW Architects
  • John Williams, construction review services manager, Washington State Department of Health

ASHE recently interviewed the team to learn more about the study and what the findings may mean for the future of rural health care.

Q: Why is your national benchmarking study important?
A: (Cai) The purpose of this benchmarking research is to provide an overview of the current status of CAH design across different regions with the hope of identifying trends and possible alternative typologies for CAHs. For example, the national trend in health care is to design larger private rooms in hospitals. The study will tell us if a similar trend applies to CAHs. More importantly, this study will provide solid evidence to inform the Facility Guidelines Institute regarding future CAH guidelines.

(Lewis) The study’s findings will influence future regulatory standards in many different states. It will allow these unique project types to develop as they need to rather than be built beyond their capacity.

(Williams) Rural hospitals are an important component of the health care delivery system. Despite the large number of CAHs, the discussion around regulatory standards tends to focus on urban facilities. Studies like this bring a different perspective and help us understand the needs in rural communities.

Q: What are some of the unique design challenges that critical access hospitals face?
A: (Lewis) There are many. Some of the top challenges include:

  • Geographic isolation making access to care very difficult
  • Income level disparities and inability to afford care
  • A small labor pool affecting recruitment efforts
  • Lack of patient transportation
  • Service disparity or difficulty finding specialists to provide services
  • Difficulty accomplishing integrated health care
  • A lack of technology
  • Higher construction costs when resources are scarce

For example, telemedicine is a very up-and-coming trend in major health systems. Often CAHs do not have the infrastructure to support this technology and provide this service.

(Cai) It’s common for CAHs to experience limited staffing. A unique challenge that CAHs face is designing to maximize resources and allow for the cross utilization of staff. For example, the adjacency of departments is very important to facilitate movement of staff between various areas. In addition, when staff are shared, the facility may be able to reduce the office space in each department and use the area more efficiently.

(Williams) Some rural facilities make construction decisions based on one provider’s practice. This is inherently risky and can drive delays and changes. Some populations simply are not at the point to make dedicated service lines feasible. This drives the need for flexible, multi-purpose spaces. The FGI Guidelines have acknowledged these types of challenges by creating a separate chapter for smaller hospitals. Hopefully studies like this can inform the next iteration of that chapter.

Q: “One size does not fit all” when it comes to CAH design. Can you expand on this?
A: (Lewis) No two projects are the same. Facilities should look to fundamental, attributable research to guide their design. A CAH is going to survive when the facility effectively meets patient demand and is built in a way that allows the CAH to reach its goals.

(Cai) A CAH serves a specific community and the demand from that community will dictate what size the facility should be. For example, some neighborhoods have 25-bed facilities with high occupancy rates while others are shrinking to 8-bed facilities and are still not filling up. Demand can depend on a variety of factors, such as how close the CAH is to a larger, regional hospital. It all comes down to finding the strategy that is appropriate for the local community.

(Williams) Communities are certainly different with different needs. Part of the challenge comes when we label the building as a “hospital.” Hospitals come with both benefits and regulations. Regulations will often set requirements for what services have to be provided based on how you are licensed or certified. Certification is linked to reimbursement and the entities that pay will often have an expectation for what services should be provided. Licensure is driven by regional expectations of safety, accountability, and social contract. Providing more perspectives into the decision-making process around those regulations can evolve those expectations. Once a facility chooses to provide a service, certain universal design features should apply. Why should one facility be less prepared for a planned service than another? The difference between the optional and the necessary is a core discussion when developing the Guidelines.

In the team’s PDC Summit session, Rural Right Size Study and FGI Response the team will present their preliminary findings and share how the study can be used to influence future regulatory approaches for CAHs.


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