International Union of Architects/Public Health Group Forum

1. International Union of Architects/Public Health Group Forum September 26, 2013

2. Humber River Hospital • North West Toronto, Ontario • Central LHIN • Catchment Area of 850,000 • Diverse high needs community • Providing service on 3 sites • 3 outdated facilities within 10 mile radius • 600 physicians, 2800 staff , 300 volunteers • Affiliate - University of Toronto

4. Humber River Hospital – Today

5. Redevelopment Vision • One full service acute care facility on a Greenfield site bringing together all acute care services to create the volumes for centers of clinical excellence and efficiency • An ambulatory site for urgent care services in the highest need area of our community

6. Planned Growth

7. Alternate Funding Procurement (AFP) in Ontario • Released in July 2004, the Building a Better Tomorrow Framework sets out the Province’s approach to infrastructure planning, financing and procurement, including when the Province will consider using AFP strategies. • Five key principles under the Framework: – Public interest is paramount – Value for money must be demonstrated – Appropriate public control/ownership must be preserved – Accountability must be maintained – All processes must be fair, transparent and efficient

10. Alternate Finance Project (AFP)Design Build Finance Maintain (DBFM) • Use of private expertise and financing to rebuild public infrastructure • The public sector is responsible for establishing the scope and purpose of the project and paying for it with a long-term stream of payments. • The private sector is responsible for design, construction, financing and maintenance/lifecycle of the facility over the term of the contract (usually 30 years).

11. What is an afp OR dbfm Project? • A.K.A. - Public Private Partnerships, or Performance Guaranteed Facility • Private partner - Design, Build, Finance and Maintain infrastructure (greenfield or renovations and expansions) • Facilities management over a long term concession period (in this case 30 years + construction) with pre-defined hand back conditions • Single entity (“Project Company”) contracts with a Public Sector Sponsor entity and in turn contracts with consortium partners • Performance based contracting arrangements • On-going payments are subject to deduction for failures in service delivery • Firm price for term of the concession

12. 40 Year Facility Cost of Operations1 Note 1: From July 2010 Healthcare BIM Consortium ,An Organization consisting of Department of Defense Military Health System (DoD MHS), Department of Veterans Affairs (DVA), Kaiser Permanente (KP), and Sutter Health, representing $26B of Healthcare construction

13. “Value for Money” – DBFM Project • Long term “Whole of Life” costs instead of first cost construction • Good decisions during design process consider Value for Money and best investment approach • Results in lower whole-of-life facility cost (the “box” is smaller) • Facilities management over a long term concession period (in this case 30 years + construction) with pre-defined hand back conditions • Provides outcomes that are guaranteed as a result of performance requirements • Financing returns are vehicle for Sponsor to enforce the guarantees

14. Our Future 14

15. Developing our Vision Considerations • An opportunity to design efficiently • Patient Centered • Capital is one time – operating is forever • Designed to make a big hospital feel small • Designed to be more accessible • Separation of inpatient and outpatient services • Respect for interventional procedures • Piazza type gathering areas

16. Developing our Vision Considerations • An opportunity to design efficiently • Patient Centered • Capital is one time – operating is forever • Designed to make a big hospital feel small • Designed to be more accessible • Separation of inpatient and outpatient services • Respect for interventional procedures • Piazza type gathering areas

17. Current Evolution of Hospitals • Deliver high quality, patient centered care cost effectively • Maximize efficiency of limited human resources • Allow clinical staff to focus on providing care – reduce administrative tasks! • Minimize equipment redundancy and maximize equipment utility • Optimize inventory turnover

18. Current Evolution of Hospitals • Health, health care and the environment are inextricably linked. The design and construction of a new hospital should be a model of sustainability, efficiency and achieve LEED® rating • Impact operating budget to save energy costs

19. Current Evolution of Hospitals • Utilize the most current technologies possible to enhance all aspects of quality care and efficiency. • Leverage technology and push technology wherever possible to improve efficiency,accuracy, reliability and safety.

20. Healthcare Reinvented Green Patient Centered Care Work Place of Distinction Lean Digital

21. vision : LEANGREEN DIGITAL • Philosophy of form follows function • Maximize Clinical Efficiency - deliver cost effective care in one of the largest hospitals in Ontario through design, staff mix and appropriate technology mix. • Allow for smooth movement of patients, staff and visitors while reducing waiting times. • Computer modeling and lean workflow analysis to test design possibilities to ensure efficient flow and reduced travel time

22. Efficiency by Design Bigger, Nicer, Newer but actually LESS EFFICIENT in delivering care

23. Why Worry? • Current size on 3 sites = 980,000 sq feet • New facility = 1.8 million sq feet

24. HRH Travel Distance Problem GE HoF study demonstrated Total Distance Traveled in Current HRH Facilities: Medical Inpatient Nurse walks 5.4 km per 12 hour shift Use current technology, same model of care in modern space and design standards Medical Inpatient Nurse walks 11.6 km per 12 hour shift

25. Evaluating the Vision Elements

28. LEAN, GREEN and DIGITAL

29. Delivering the vision GREEN SUSTAINABLE, ENERGY EFFICIENCY 100% FRESH AIR THROUGHOUT ASHRAE 90.1-2007 40% ENERGY SAVINGS SUN/SHADE MANAGEMENT STRATEGY 40 % DECREASED ENERGY CONSUMPTION MAXIMIZE CAMPUS GREEN INTIATIVES

30. If we take a hospital with a first year utility bill of $5,500,000…. The Energy NPV is $223,124,436 If we reduce the annual utility rate by 40% than our Energy NPV is… $133,874,661 (30 years) That’s a difference of $89,249,775 (30 years) DBFM: ENERGY AND NPV

31. Energy Model in DBFM • Energy Consumption is the responsibility of the operator • Cost of Energy is paid by the hospital • DBFM model rewards energy efficiency with a pain share/gain share model

32. Evaluating the Vision Elements

33. LEAN, GREEN and DIGITAL

34. PHYSICAL PLANT • Site and Gross adjacencies • Departmental Layouts • OPERATIONAL STRATEGY • Staffing Levels • Task Assignment • Shared Resources • CARE DELIVERY • Clinical Pathways • Technology Adoption • Local Practices

35. Increase Efficiency • Maximize efficiency of limited human resources • Allow clinical staff to focus on providing care – reduce administrative tasks! • Minimize equipment redundancy and maximize equipment utility • Optimize inventory turnover

36. Interoperability

37. Elements of the Digital Vision? • Digital components • IP Network • IP based equipment • Unified communications • Digital content management • Automation components • Automated Guided Vehicles • Pneumatic Tube System • Pharmacy automation • Laboratory automation • Surgery automation • Interoperability • Workflow orchestrations • Interoperability engine – Enterprise Service Bus • Service Oriented Architecture • Abstraction • Governance