An optimised approach to healthcare infrastructure programmes is the key to developing successful healthcare facilities, says Andrew Parks, Managing Consultant at Mott MacDonald
Healthcare infrastructure programmes throughout the world are fraught with difficulty. Planning and funding approvals are rushed, and processes are heavily influenced by political agendas and optimism bias. Construction often runs over time and over budget. Then, the combination of short cuts in early decision making, combined with the speed of clinical and technological innovation, means. this immovable structure, once finally opened, quickly becomes obsolete and reflects an outdated clinical practice that cannot cope with a changing patient population. Yet, all indicators point to the need for more and more healthcare facilities, so we must find a way to deliver more effectively that isn’t a burden to Governments and taxpayers.
Where are we getting it wrong?
A look at previous health infrastructure programmes indicates that they go wrong for several core reasons. These appear to be ineffective governance and decision making, inability to manage the inherent complexity and constant reinventing solutions to the same problem and not learning.
Firstly, ineffective governance and politically motivated decision making, based on biases and assumptions, causes subjectivity and overoptimistic estimates. There is a lack of evidence-based decision making. Decisions are rushed and based on narrow data sets and too many assumptions, concluding the best option is to build acute hospitals before thorough analysis has begun. The only question asked is what should be built, not should we build. Evidence shows, however, that to cope with growing demand, allow flexibility and improve patient experience and outcomes, there needs to be a shift away from the provision of all care within an acute setting, to a system that can utilise community and at home services, driven by technology and digitally enabled care that allows patients to take more control. Simply put, huge capital investments are committed without thoroughly testing alternatives approaches.
Secondly, project management and technical capability is not able to manage the high degree of complexity in healthcare infrastructure. Instead of the integrated approach required, a linear, fragmented methodology is used with each element developed in isolation. Healthcare delivery systems are highly complex, adaptive systems and represent a “wicked” problem. Without understanding the interfaces properly, any changes intended to solve one issue will unintentionally create issues elsewhere in the system. This approach drives constant scope changes and design difficulties which are expensive and, when combined with human behaviour, drives decision making that results in short cuts.
Healthcare infrastructure projects are high risk, yet few lessons are learned and passed on between projects, repeating the same mistakes. In addition, every hospital is seen as special and bespoke, and new solutions are created to solve the same problem. This is clearly problematic and inefficient, but more importantly creates productivity challenges for the construction industry. A single hospital project is a highly complex building programme – if every hospital is built differently, the risk profile never reduces, no delivery learning is passed on, so productivity never improves.
However, it is possible to adopt an approach to develop healthcare infrastructure that allows for objective decision making, one that meets present and future need, solves the design challenge once, balances the multiple perspectives with the needs of the patient at its core. This approach creates an environment that staff want to treat patients in and is ultimately systematised so it can be used repeatedly and improved.
What can we do about it?
An approach that harnesses systems thinking to solve these issues and optimise the way healthcare infrastructure is delivered is possible. This approach responds to the need for better decision making and embraces new care models to meet changing demand and demographics. It uses systems thinking and systems engineering to manage the complexity and interfaces. It adopts an innovative industrialisation model to learn lessons and drives efficiency to deliver new infrastructure within constrained social infrastructure budgets. The opportunity is greatest when this approach is applied to a group of healthcare projects as it drives economies of scale.
Strategic healthcare planning
Step one is to be disciplined in establishing and defining the future demand and system level change requirements. An aspirational future state developed using advanced demand and capacity modelling should reflect the ambition to optimise models of care and create new ways of working, not simply to justify capital investment. It is here where alternative options need to be fully tested and supported with real world data.
From this analysis, a set of aspirational, transformational principles are established to define the strategic purpose of the programme. This set of principles needs to be converted into measurable programme goals that define the transformational vision of the programme and the core focus areas.
Using systems thinking to manage complexity and drive integration
Healthcare infrastructure programmes are often wide ranging and ambitious, and the scale and complexity lend itself to systems thinking. The sheer quantity of people, scale of resources and other factors creates a complex, adaptive system. Using systems thinking allows a holistic approach to conceptualising this complexity and helps to find system logic.
This logic can be mapped, and limits and remits established. Combined with the strategic programme goals, it allows a programme strategy to be defined, allowing all stakeholders to work to the same understanding and start to create a single integrated approach with a common purpose by reimagining the traditional approach to problem solving.
Systems engineering and developing a platform
This programme strategy is then handed to a multidisciplinary team to establish a set of corresponding programme requirements. Through identifying best practice and lessons learned, they develop a ‘platform’ of standardised solutions or a kit of parts that meets these requirements. This platform is ideally broken down into a series of groupings or modules of individual solutions to help manage the complexity and create the opportunity for repetition, learning and specialist knowledge to developed in defined areas.
The approach taken to develop this platform is not traditional and instead uses an industrialisation process to remove unwanted variability. Designers start with how the infrastructure will be built and how operational interfaces work.
By integrating functions such as clinical, operational, technical, commercial, delivery and digital they find the best delivery method, and manage the interfaces and operational functions for each optimised component. In learning from other industries implementing similar approaches, early consultation with the market is key to clarify any core strategies (e.g. modularisation) that might cause issues and to identify any areas of supply constraint that might require substantial market change.
In essence, this set of rules enables the development of infrastructure to move forward within parameters that reduce variation, increase repeatability, and provide more granular information with the pipeline of demand, supporting more detailed engagement with the market and stakeholders – ultimately reducing risk and allowing for productivity improvement. The programme then uses configuration management to test and validate the platform ensuring it achieves maximum impact and is aligned to the core transformational objectives.
Implementation and deploying the platform
Elements of the platform are then taken and assimilated into each project in the programme. As a result, rather than the same problem being repeatedly solved, the platform has already identified best practice and opportunities for repeatability still allowing for the right level of variability for key stakeholders. At this stage an innovative procurement model is required that allows deeper early contractor and supply chain collaboration. The proposition is that the supply chain is entering a streamlined workflow where variations in the brief have been significantly reduced.
Buildability has been considered a core principle, and there is still time to influence the design development. It is important to consider alternative delivery models to open the market to new entrants. This critical step will bring two key benefits: improving delivery performance while simultaneously opening the opportunity for more innovation.
Due to the nature of healthcare programmes, it is highly likely that time pressure will be a factor. Therefore, the implementation of the approach can align to the sequence of the development of each project. The programme can achieve benefit at all levels of maturity of the platform. Immediate impact can be achieved by simply reducing variability and stabilising design requirements. It is vital to continuously check back and validate the performance of the platform against the measurable objectives during both the development and deployment phase to ensure alignment with programme goals.
The principles set out in the programme strategy become a core component to achieving early impact. If an early adopter can achieve the principles of the programme through a traditional delivery method while the platform is developing, the programme can both move forward, and critically, learn lessons. The new delivery methodology that the platform enables then cuts into the programme at the most appropriate times. Ultimately, facilities developed using the full platform will have maximum impact, but this effect will take time to achieve and needs learning from experience to get to this point.
Future optimised delivery
If this process is done right, this approach can transform the way healthcare infrastructure is delivered for governments. The ‘platform’ can evolve into a space where continuous improvement, lessons learned, and innovation can continue to thrive. In essence, every time we build healthcare infrastructure, we learn and get even better at building it.
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