Anyone moving into a new home has been struck by its oddities. Why is the light switch on the other side of the room to the door? Why is the TV aerial so far from a power point that an extension cable has to be used? Why is the boiler so far away that it takes many minutes to get hot water in the kitchen? Who on earth made those choices? 

Similar questions tend to arise at the end of any hospital construction or refurbishment when the people who will use those new facilities the most start to engage with the new space. So, what could be done better to ensure the final product better meets the needs of those using it? 

Q-bital Healthcare Solutions recently hosted a roundtable discussion with clinical staff, operations and facilities managers, builders and contractors. Participants all expressed their frustrations with funding flows and the current, inflexible system of capital works and shared some ideas for better ways forward. 

Here’s what they had to say: 

Recognise that telehealth changes how space is used

Healthcare Spaces of the future may need fewer large waiting areas and more private offices for doctors and nurses to provide virtual care. Existing spaces could be repurposed now to enable this. 

Practically what we can look at is doing pre-assessments, pre-clinical work remotely, being able to do it from home. Quickest thing we can do. It is infrastructure but it’s not a big deal.
Participant in the Q-bital Roundtable

Standardise room design to help with staff shortages

COVID-related immigration restrictions, sick leave and resignations have intensified Australia’s healthcare staffing shortages. 

Health Workforce Australia estimates that could be a shortfall of 100,000 nurses by 2025, worsening to 123,000 by 2030. 

That workforce shortage must be addressed at a high level through better terms and conditions that increase nursing’s appeal. The reality of such significant shortages must also be navigated at the ground level. 

For some time to come, hospitals may be relying on casual agency staff or deploying personnel to wherever they’re most needed, irrespective of their usual stations. That means many staff are working in unfamiliar settings, moved from one part of the hospital to another as the need arises and constantly adjusting to different ways of working. 

Standardising the design of patient rooms helps to create a familiar environment for healthcare professionals. Because every room is organised in the same way, they instinctively know where to find supplies and equipment no matter which part of the hospital they’re working in that day. This overcomes disorientation and can improve efficiency and care. 

As one participant in the recent roundtable said, 

All rooms [should be] the same so it doesn’t actually matter what staff goes into what room it’s all set up the same it works the same, the nurse call system is set up the same…so regardless of what training you’ve had and what your specialty is, when you walk into the room it’s the same, it functions the same. I think that’s a big innovation…and certainly I would take it. 

Aged care: It’s not only about more nurses, it’s about incentivising good patient care

The federal government is keen to get more registered nurses (RNs) into aged care facilities, offering incentive payments for clinical leadership to nurses who remain at the same aged care facility for 6 or 12 months. 

That went down like a lead balloon with roundtable participants who felt that almost nothing would tempt registered nurses to work in aged care under current conditions.  

My grudge there too, [aged care] is very cost-driven so registered nurses are too expensive. So, there’s a lot of other levels of care that are put in place in the place of a registered nurse, but then you don’t get registered nurses wanting to work in those facilities, because there’s the weight of that responsibility of overseeing everybody as well. So, you haven’t got that supervision that you want, because you can’t get the staff, because the conditions aren’t great. So, there’s that parameter as well.
Participant in the Q-bital Roundtable

Funding mechanisms also need fine-tuning to ensure they incentivise the right goal – that of keeping residents as mobile as possible to support their physical and mental wellbeing. 

Ideally, residents of aged care facilities would be supported to maintain their mobility, getting in and out of bed themselves. Overseeing that process takes time and patience on the provider’s part. It also deprives them of funding. That means there’s no incentive to do it, even though it’s far better for older people themselves. 

There is, however, additional financial support for caring for patients with disability. It’s quicker, easier and more lucrative for the organisation to treat residents as if they had a disability rather than support them to maintain independence. 

Actually, age care currently is set up to provide additional financial support for people being disabled so there is no incentive to get someone out of bed themselves. If I continue to hoist patients in and out of bed, that makes my job easier, it gets us more funding and it means I can move to the next person.
Participant in the Q-bital Roundtable

 Funding is certainly needed for residents with true disabilities but perverse incentives in the current system need to be addressed. 

Service redesign is important

Others felt that these conversations were beginning to happen. 

I think more and more the centre is starting to ask us, have you used every part of this asset that you possibly could use, have you tried everything you can to make it more functional, more efficient, more useful for you?
Participant in the Q-bital Roundtable

Include the right people in decisions on new facilities

Roundtable participants noted the requirement to consult clinical teams in the design process but felt that the right voices were not being heard. Input from a grassroots rather than managerial level is often the most useful. 

You’ll get people up here making decisions for the people down here so, there is a big gap between what these guys think needs to happen down here and what actually needs to happen down here.
Participant in the Q-bital Roundtable

So they had a workshop the other day and it was the first time they got 12 scrub nurses into a room and the staff that came were fully functional staff. [They were asking things like] can we put this next to the light switch.
Participant in the Q-bital Roundtable

Build flexibility into construction contracts

The pandemic has created something of a tree-change with significant numbers of Australians leaving capital cities and moving to the regions. In fact, about 17,200 people moved from Melbourne metro into the regions in the year to September 2020, eclipsing by 25 times the number who had moved in 2019 (when just 7,000 Melburnians decided to leave). Regional areas outside capital cities had a net gain of 36,200 people, the highest on record.  

The Regional Movers Index, a collaboration between the Regional Australia Institute and the Commonwealth Bank, found that those moving to regional areas rose to 16.6%, reaching a 5-year high in the March 2022 quarter and almost doubling pre-pandemic levels of movement to the regions. 

It’s wonderful news for regional economies but can cause headaches for healthcare planners with capital works in progress that now need to cater to an expanded population. 

Many participants expressed their frustration with capital works contracts that locked them into decisions too early and lacked the flexibility needed to change with changing times. 

They’re scoping out the contract for years before the hospital’s actually built. You need some ability to have a negotiation process so you can change some scope. I think that sometimes when it is a government process, there are limitations put on by certain stakeholders to put forth changes.
Participant in the Q-bital Roundtable

With the green change though, obviously there’s been an initial burden on the hospital’s location. At the moment [a hospital in regional Queensland] have extended [their surgical capacity] as a result of COVID migration and there’s been another surge in demand and that we probably need to extend the capability again. How do you keep doing that and planning for that thing, when you are talking about sustainable design over a period of years and do master plans and have an outlook, how do you commit to that?
Participant in the Q-bital Roundtable

Participants felt that early contractor involvement should be encouraged. Many builders around the table felt that they had considerable experience and expertise to share at the planning stage yet were not usually brought in until all the plans had been finalised. 

We always keep coming on the last stage so, we don’t have an opportunity to help with the facility itself, to be able to make it more user-friendly…we come in a month before we start, procure everything and go and build it. Whereas some people will just say, you’re just a builder so go and build what we told you to do.

But after we finish it, questions arise such as. “Why’d you do that? Why is that like that? What’s happening here? Why didn’t you do that like that?”

We’re builders – we understand what needs to happen and what facilities need to be like to accommodate 30 end users.
Participant in the Q-bital Roundtable

One solution favoured by the participants was the use of NEC4 contracts that enable flexibility in the design and construction process.  

These are standardised contracts which protect each party’s interests but are not prescriptive to the point where they dictate the result. Rather they tend to speak to a high-level functional brief that describes what the facility is required to deliver and the levels of care to be provided. 

Armed with that high-level brief, the provider must supply a compliant infrastructure solution that complies with defined design frameworks such as the Australian Health Facilities Guidelines (AHFG) and the National Construction Code (NCC). 

This is a welcome change from other contracts that define arbitrary details down to minutiae – such as whether a power point was placed to the left or right of the data ports. Such prescriptiveness has meant that builders were contractually obliged to deliver that specific requirement, even when it later became clear that it was not the best choice. Unless there is a clinical basis for the request, a functional brief would merely denote the need for power and data at a given location to run a certain piece of equipment. This enables the parties involved to make wise decisions on the ground at the right time in the project rather than being forced to deliver something agreed in a board room that is clearly not fit for purpose. 

NEC4 contracts are widely used in the UK and are becoming more popular in Australia with flexible infrastructure providers such as Q-bital. Cumbria County Council in the north-west of England credits NEC contracts with the delivery of their entire infrastructure recovery program, explaining that

The contract suite was chosen primarily because of its approach to collaboration, risk mitigation and commercial flexibility. NEC contracts are also proactive, add value and are written in plain English.
Caroline Leigh, Cumbria County Council

Where to from here? 

Participants in the roundtable discussion clearly had a great deal more to share on these topics. These are important conversations that need to continue. 

As the host of this roundtable discussion, Q-bital strongly encourages early engagement with suppliers like ourselves. 

Comprehensive early stakeholder engagement with the hospital, suppliers, grassroots staff, contractors, patients and community forms a vital part of the dialogue to develop a functional brief as mentioned above. 

Once that functional brief is ready, it is time for a rigorous procurement process where competition is encouraged. Too often, though, according to roundtable participants, that procurement process happens too early, locking people into a rigid contract instead of a more valuable functional brief developed with early stakeholder engagement. 

If you would like to learn more about functional briefs, NEC4 contracts or the benefits of flexible infrastructure, please contact Q-bital Healthcare Solutions.