Relocation of hospital facilities: guidelines for resilient performance

Abstract

Background

The relocation of a hospital unit is a complex process that demands both formal planning and informal self-organization on the spot to cope with unexpected events under time pressure. However, guidelines to support this process are fragmented and concealed in the literature. This article addresses this gap by presenting guidelines for the relocation of hospital facilities, using the complexity-informed lens of organizational resilience.

Methods

The guidelines were based on the study of relocating a surgical unit, in which the new facilities were approximately 400% larger. Data collection involved interviews with professionals holding leadership positions in the relocation project, non-participant observations of the meetings of the relocation project committee, and guided tours at the old and new facilities. An initial deductive thematic analysis was conducted to identify instances of resilience and brittleness. Then, inductive reasoning gave rise to the relocation guidelines.

Results

Seventeen guidelines for resilient relocation of hospital facilities are proposed. All guidelines are applicable to the period before the change, highlighting their proactive nature. They also operationalize seven principles of designing for resilient performance, mainly those related to the provision of slack resources and creation of opportunities for learning.

Conclusions

The guidelines consist of new prescriptive knowledge, explicitly connected to the resilience perspective. They are particularly relevant to hospital managers that lead the relocation process.

Introduction

Hospitals are complex adaptive systems composed of a large number of diverse social, technical, and organizational dynamically interacting elements such as caregivers, patients, equipment, and management routines [1]. Such systems are constantly evolving to cope with changing demands, which in hospitals include expansions, refurbishments, and relocation to new facilities [2, 3].

These changes in facilities are complex themselves as they involve several stakeholders, trade-offs, and interdependencies [4]. In an Australian hospital, staff described the relocation process as highly complex, with frequent unexpected difficulties that required revision of plans [5]. As a consequence of this complexity, the relocation of healthcare facilities demands resilient performance, which is "the ability of the healthcare system (a clinic, a ward, a hospital) to adjust its functioning before, during, or after events (changes, disturbances, and opportunities) and thus sustain the required operations under both expected and unexpected conditions" [6]. Indeed, the relocation involves a proactive resilience dimension, concerned with the anticipation of changes, as well as a reactive dimension that responds to unexpected and to some extent inevitable events. In fact, complex adaptive systems are intrinsically resilient to some extent, or otherwise they would cease to exist [7].

This paper investigates resilience in the relocation process of healthcare facilities, rather than in the design of the new facilities as a product. Despite the importance of product design, it is a vast topic concerned with built environment design decisions that deserve their own in-depth research, being out of the scope of this paper. Prior studies discuss how the built environment design can explicitly support resilience in the operation of hospitals [8, 9]. The present article assumes that major built environment design decisions (e.g., site location, size) are made and cannot be changed. The scope of this paper encompasses the planning of the move to the new facility, the actual physical transition to it, and the immediate post-relocation period.

There are some works on the relocation of hospital facilities, focusing on surgical units [2, 10] and intensive care units [11,12,13]. These and other studies make it clear that the relocation is more than a physical change, with implications to work organization, safety, and well-being of caregivers and patients [10, 14]. Nonetheless, the description of these implications has not been followed by the development of prescriptive guidelines that can be used proactively by designers, health care managers, and policy makers. Moreover, although prior studies recognize the relocation complexity and the need for resilience, their theoretical frameworks are not explicitly linked to these themes. This drawback hinders learning opportunities valued by complexity and resilience such as those related to coping with unexpected events and using informal problem-solving practices [15]. Such learning is even more likely to be overlooked if positive outcomes are achieved in the relocation, leading higher hierarchical ranks to neglect the role of informal self-organisation and believe that plans fully worked as imagined [16].

Against this background, the research question addressed in this paper is set out as follows: how to support resilience in the relocation of hospital units? To address this question, we propose guidelines for resilient relocation, based on a study of the relocation of a surgical unit in a large hospital. Surgical units offer life-saving care to patients who will often be hospitalized for days or weeks in areas such as in-patient wards and intensive care. Additionally, surgery is a major source of revenue for hospitals, and the financial fallout from lengthy relocations can be severe. Instances of resilient performance and brittleness were identified from this case study. In the realm of resilience management, the term brittleness denotes technical, social, and organizational vulnerabilities that can either reduce the desired impact of resilient performance or be an unintended and undesired consequence of it [17, 18]. In a higher level of abstraction, an analysis was carried out of how these instances related to principles of Designing for Resilient Performance (DfRP), defined as "the use of design principles to support integrated human, technical, and organizational adaptive capabilities" [19]. Further analytical reasoning produced the relocation guidelines, which are new and of interest to all stakeholders, and in particular to hospital managers who lead this process.

Background

Design for resilient performance

The literature that uses the term design for resilience (rather than for resilient performance) focuses on how technical systems (e.g., building, bridge, medical device) can be designed to withstand physical forces, natural and man-made disasters [20, 21]. Healthcare facilities have been approached from that perspective. For example, [22] offer guidance for the design of hospital facilities that cope with disasters such as the COVID-19 pandemic.

This article adopts the previously mentioned definition of DfRP, which is interested in the design of socio-technical systems supportive of resilient performance. Differently from technical systems, socio-technical ones are ensembles of human, technical, and organizational sub-systems, subject to interactions with the external environment [23]. Therefore, DfRP fits our stated interest in the relocation process, which has a socio-technical nature.

Table 1 presents the principles of DfRP set out by [19]. These principles emerged from a Delphi study with resilience engineering experts from several countries, encompassing social, technical, and organizational dimensions. They are aligned with the widely cited four potentials of resilient systems—monitoring, anticipating, responding, and learning [24] and recognize key tenets of resilience management such as the inevitable differences between work-as-imagined and work-as-done [25].

Table 1 Principles of designing for resilient performance, adapted from [19]

These principles have been used as analytical framework in several investigations, including: [19, 26] for understanding how rapid response teams and huddles support resilience in hospitals; [27] for the identification of resilience requirements of digital technologies in hospitals; [28] for assessing the contribution of participatory practices for resilience in construction projects; and [29] for the analysis of how production planning and control enhances resilience in construction. [30] used a similar set of principles for developing guidelines for the design of built environment supportive of resilience in hospitals. Thus, the principles of DfRP have considerable validity and have proved to be useful for resilience assessments.

Relocation of hospital facilities

The relocation of a hospital ward involves the redesign of both the built environment and operational processes [31], affecting behaviours of healthcare professionals in the new facility [32]. Oversimplified design assumptions, which do not reflect the complexities of healthcare, lead professionals to adapt entirely through informal self-organisation, increasing the possibility of unwanted unintended consequences [13].

Frequent difficulties in hospital relocation include ineffective communication between members of the relocation project team [14], changes in plans [14], neglect of the need for staffing the new facilities [33], and the lack of involvement of frontline professionals [14]. In addition, [34] add that the relocation of a hospital unit poses risks to patients due to operation below full capacity in the initial post-transition period and the lack of familiarity of caregivers with the new environment. Measures to address these and other challenges have been identified such as appointing an influential leader to communicate the project progress to employees [32], providing training and workflow simulations to prepare the teams for the new workspace [35], and reducing or stopping elective surgeries to free up staff during the transition [36]. However, the last one can create further problems. In the relocation case reported by [10], elective surgeries were suspended during 15 days, and there was a one-month post-move stabilization period for teams to adapt to the new flows. This resulted in a backlog of 1400 elective surgical procedures, which persisted for two years after the move [10].

The aforementioned studies suggest that resilience is necessary and in display in hospital relocation – e.g., when workers learn by doing in the post-relocation, when plans are adjusted, and when a unit borrows margins from another. However, the resilience concept is hardly mentioned, and therefore learning opportunities from this perspective have not been effectively explored.

Research method

Research design

This research was conceived as a case study, which is recommended for analysing complex phenomena in their real context, and when the researcher does not have any control over the data collection environment [37]. The studied surgical unit is part of a large public university hospital in Brazil (approximately 6000 employees and 836 in-patient beds), which underwent an expansion with the construction of two new buildings, adjacent to the existing facilities, and delivered in 2019. One of these buildings was intended to accommodate the surgical unit, intensive care unit, emergency department, pathology unit, and sterile unit. The surgical unit was the last to move to the new facilities, in mid-2023. The others had been relocated during 2021 and 2022. This setting offered a considerable complexity and therefore a rich empirical context for investigating the research question, justifying its selection.

Data collection and analysis accounted for three stages of the relocation process, namely the relocation planning, the transition itself, and the immediate post-relocation of the unit. The research project was approved by the hospital’s research ethics committee under the approval number CAAE 79424617.0.0000.5327.

Data collection

Data collection was based on three main sources of data: non-participant observations, semi-structured interviews, and documents. In non-participant observations, the researcher watches the subjects of their study, with their knowledge, but without taking an active part in the situation under scrutiny [38]. As such, there were 35 h of observations, including: visits to the facilities of the old and the new building, and 19 online weekly meetings of the relocation project committee, composed of representatives from 50 hospital areas. The visits (10 h in total) were guided by members of the hospital staff and allowed us to get acquainted with the layout of the facilities, observing differences between the old and new ones. One of these visits, lasting four hours, involved the observation of a simulation of the patient flow in the new building, shedding light on the effectiveness of the new layout and the need for adjustments in plans. This simulation counted on the participation of clinical leaders, architects, and industrial engineers. In turn, observations of the meetings of the relocation committee (25 h in total) offered plenty of opportunities to understand the planning of relocation, associated activities and difficulties, many of which counted as instances of resilience or brittleness.

Nine semi-structured interviews were carried out after the transition to the new building, aiming at understanding how the principles of DfRP had been accounted for in the relocation process. For this purpose, an interview guide was used (see Supplementary Material), containing questions associated with the seven principles of DfRP. All interviewees were members of the relocation committee and had leadership positions in this project, including: industrial engineer, head of the sterile unit, head of the day surgery unit, adviser of the hospital director for strategic planning, adviser for patient care, head of the quality management department, head of the anaesthesia service, head of the postoperative service, and nursing-chief of the surgical unit. The interviews were audio-recorded and totalled 4.1 h, being transcribed verbatim.

There was also a documentary analysis involving: the floor plans of the new facilities; diagrams of the new patient flows; the relocation schedule, which offered insight into the activities, sequencing, and time-pressure; and training materials for using the new facilities. Documents played a complementary role to the other data sources, permitting a deeper understanding of the manifestations of resilience and brittleness.

Data analysis

A thematic analysis was carried out to analyse the interview transcripts and notes from observations, following the steps recommended by [39]: familiarization; identification of themes; coding; charting; mapping and interpretation. Initially, the raw texts were read several times to obtain familiarity with the data. Next, in order to ensure consistency with the research question, two themes were defined upfront, namely instances of resilience and instances of brittleness in the relocation process.

A mixed deductive and inductive approach was used for coding. Initially, in first-order coding, deduction was used to identify excerpts of text associated with instances of resilience or brittleness. This identification gave rise to codes that described either resilience or brittleness (i.e., short statements that encapsulated the instance). Then, an inductive analysis was performed to re-interpret the initial codes, producing second-order codes that prescribed how resilience could be supported during the relocation process. The second-orders codes were more often than not the flipside of the first-order codes, and therefore the re-interpretation used to be straightforward. For instance, there was a first-order code stated as “several hospital units moved in before the surgical unit, making it possible to learn from their experiences and raise questions that otherwise would be neglected”. This was re-interpreted as the following second-order code: “learn from the experience of other units that relocated in the past”. The second-order codes correspond to the relocation guidelines that directly answer the research question.

There was another layer of deductive analysis that explored the relationships between all first-order and second-order codes with the principles of DfRP presented in Table 1. For example, the aforementioned code “learn from the experience….” was linked to the DfRP principle “design to support continuous learning at the individual and organizational level”. Still regarding this example, piece of evidence of learning was obtained from both interviews (i.e., interviewees stressed the potential of learning from past changes) and observations (i.e., the researcher witnessed discussion of learning from past changes in the weekly meetings of the relocation committee). Such triangulation of data and data sources was doable in several other codifications. All levels of codification were manually conducted by the first author and responsible for data collection, and thoroughly reviewed and revised by the second author, who also read all transcripts.

The thematic analysis proceeded with the charting stage, in which all first and second-order codes were presented in a tabulated format. Finally, in the mapping and interpretation stage, the relocation guidelines were analysed as a whole set and discussed in light of extant literature.

Results

Main characteristics of the surgical unit

There were two main types of surgical procedures: elective scheduled, and urgent unscheduled. For the latter there was an operating room (OR) on standby, while elective procedures were scheduled by a doctor or resident through the hospital’s computerized management system. The sterile unit was the main supplier of the surgical unit, which demanded a large number and a wide diversity of surgical instruments and complementary supplies such as gowns and masks. For this reason, both units were located on subsequent floors in the old building and connected through a dedicated freight elevator.

Although this proximity was eventually maintained in the new building, the sterile unit moved out two years before the surgical unit. This decision was due to the adoption of new advanced sterile technologies, which in the view of leadership would be too demanding to be implemented concurrently with the surgical unit relocation. Thus, during two years the two units remained in separate buildings, implying in substantial travel time (approximately 10 min each way), compounded by the need for several daily deliveries of supplies and collection of used items. Table 2 presents the main characteristics of the surgical unit, before and after the relocation. Figures 1 and 2 illustrate, respectively, the floor plans of the original and new facilities. These figures also display the main service flows and the corresponding travel distances. All distances increased in the post-relocation, demanding additional logistics effort – e.g., patient flow (176 m before, and 495 m after); sterile supplies (70 m before, and 95 m after); and contaminated materials from ORs to sterile unit (54 m before, and 106 m).

Table 2 Before and after characteristics of the surgical unit

Fig. 1

Floor plan of the old surgical unit. Notes: pop-ups show approximate distances in meters, blue line represents patient flow, green line represents flow of sterile materials, and red line represents flow of contaminated materials from ORs to sterile unit. (1) public elevator; (2) patient check-in; (3) patient changing rooms; (4) preoperative area; (5) ORs; (6) post-operative area; (7) elevator for sterilized materials; (8) storage of sterilized materials; (9) storage of case carts; (10) used supplies; and (11) elevator for used supplies

Fig. 2

Floor plan of the new surgical unit (1st floor at the bottom, 2nd floor on the top). Notes: pop-ups show approximate distances in meters, blue line represents patient flow, green line represents flow of sterile materials, and red line represents flow of contaminated materials from ORs to sterile unit. (1) public elevator; (2) patient check-in; (3) patient changing rooms; (4) preoperative area; (5) operating rooms; (6) post-operative area; (7) elevator for sterilized materials; (8) storage of sterilized materials; (9) storage of case carts; (10) used supplies; (11) elevator for used supplies; (12) patient elevator

Relocation planning

Started in 2010, the new building’s architectural design sought to meet the requirements of its users. However, in the view of some interviewees, caregivers´ involvement in the requirements identification was not effective, as illustrated by the excerpt below:

“Designers did not consider the opinion of the clinicians…this new facility is a gift for us but there was no adequate discussion regarding the service flows” (head of the anaesthesia service).

In 2014, during the initial construction phase, the architectural design underwent a review that allowed for adjustments that facilitated service flows to the possible extent. Major construction works were completed in 2019, and the transition to the new building began in 2021 with the sterile unit and the emergency department, followed by intensive care in 2022, and then surgical unit in 2023.

The planning committee for the relocation of the surgical unit counted on representatives from 50 areas of the hospital, which held weekly meetings online. Smaller teams were formed to meet at another time and discuss implications to their own areas such as nutrition, laundry, and sterile unit. Lessons learned from the areas that had been relocated earlier used to be shared during the planning meetings. This sharing used to give rise to suggestions such as the provision of staff and beds on standby in other units for coping with unforeseen events and posting wayfinding and fire safety information (e.g., evacuation routes) in circulation areas. Lessons learned can be exemplified by the following remark from the head of the post-operative service.

“The sterile unit moved earlier, and it alerted us to issues related to the different air-conditioning and telephone systems…we could prevent certain problems”.

A similar viewpoint was expressed by the nursing head of the surgical unit:

“These areas [that moved earlier] were invited to participate in the meetings and bring their testimony, strategies they used during the change, what had worked, and what hadn’t”.

The relocation planning included the provision of training for professionals from all affected units, introducing the new facilities and highlighting the main changes. The training contents were defined based on needs identified by the relocation planning committee during the weekly discussions. Each unit head was responsible for adapting and delivering the training to their respective areas. However, not all units were equally engaged in this training. The interview excerpt below, from the adviser for patient care, highlights the low engagement of the sterile unit:

“At no point we were approached by the sterile unit to discuss training needs…perhaps they thought it wasn’t important…we spoke quickly, stressing that the materials would be further away, and that the replenishment of the inventories could take longer”.

The need for planning the service flows in general stood out as there was a 400% increase of the surgical unit´s area. As a drawback, even though 64 flows were mapped and revised, they were mostly concerned with the patient journey, giving scant attention to logistics processes such as those related to collection of waste and clothing. Activities that used to require just a few steps to be carried out would take up to 50 m in the new workspace. As another challenge, the new unit was spread out over two floors (in contrast to the prior single-floor arrangement) and required patient transportation to the post-operative area through an elevator. The resulting difficulties were emphasized by the nursing head of the surgical unit:

“We had to change many nursing processes because here [new building] the patient preparation occurs on the third floor, the ORs are on the fourth, and the post-operative service is on the third. It’s a different logistics, requiring a plan to transport patients”.

The significant differences between old and new facilities were clear to employees before the transition itself, as they obtained information from visits to the area and training. Thus, it was important to engage the teams in planning for the change, and listen to their fears and questions, as pointed out in the excerpt as follows:

“The issue of people feeling insecure about the new facility came out very strongly…it was very important to listen to their anxieties. They started to get used to it, and when the change eventually occurred, they were more confident.” (head of the post-operative service).

Relocation planning was also concerned with staffing the new facilities. However, the relocation budget did not foresee hiring additional employees, which was also a slow and bureaucratic process owing to regulations applicable to public organizations. According to the head of the anaesthesia service, “we had a certain number of people to do a job in the old facility and with the change that same number would not suffice…as the unit was spread out over two floors, we had to put a person on each floor”. This same interviewee highlighted the difficulty of anticipating problems in the planning stage, which in his view was due to both the complexity of the relocation and the complacency of some members of the planning team. He argued that “some problems need to materialize so that everyone understands it…in addition, not everything can be anticipated and catch people´s attention, because the number of problems we had to solve was huge”.

Transition to the new building and the initial post-relocation period

All interviewees had a positive view of both the transition itself and the initial post-relocation period. The two excerpts below are representative of the dominant feeling.

“We did better than planned in some aspects. For example, the new unit was supposed to operate at 50% capacity in the second week, but in the middle of the first week we had more than this” (head of the day surgery unit).

“Plans are never strictly complied with, but here at the hospital we are very good at working with adjustments in plans, it seems to be a bit of our routine” (advisor for strategic planning).

Nevertheless, some adjustments and disregard for plans stood out in the interviews. One of these refers to the routes used for the transportation of materials and equipment to the new facility. Despite planning these routes to reduce interference in the hospital operations, several interviewees reported that some employees kept using their everyday paths. As an example of replanning, there was an initial proposal establishing that the surgical unit would work for a few weeks simultaneously in both new and old buildings. This approach was eventually regarded risky, and the decision was made to suspend all elective surgeries during the transition period. According to the implemented revised plan, in the first week of transition, the day surgery area (in the old building) served as a reserve for urgent procedures. Four ORs were set up at this area (one for transplants, one for heart surgery, and two for emergencies), besides a refrigerator for transplanted organs, and blood storage. During this first week there was an event that epitomized the successful transition in the view of some interviewees. This event was a lung transplant carried out at the day surgery unit, which is a highly complex and rare clinical procedure even under normal conditions. In the second week, the surgical unit at the new building was expected to work at 50% capacity, while the day surgery would remain as a backup for urgencies. In general, the interviewees felt this plan was effective, as remarked by the head of the day surgery service:

“We [day surgery unit] served as a backup for the surgical unit, and thus for two weeks we suspended most services. We prioritized oncological treatments such as chemotherapy. However, the suspension of elective surgeries had a severe impact because the waiting list was huge.”

On the other hand, the performance of the surgical unit during the first weeks and months after relocating revealed the consequences of overlooking the flows of materials, clothing, and waste. For instance, the new standardized procedure of dispensing low-cost supplies (e.g., syringes) established that employees should go to the pharmacy and pick up materials on-demand. However, according to the nursing-head, this procedure did not work as expected because professionals picked up more supplies than necessary in order to prevent long and frequent walks between the ORs and the pharmacy. There were two main implications from this approach: inventories piled up in the ORs hindering the workflow, and the need to return the materials unnecessarily picked up to the pharmacy. The nursing head felt that the relocation increased the workload of staff and the incidence of absence leaves, with consequences still unfolding as they struggled to adapt to the new environment and processes.

Changes in work organization also affected the medical teams. In the old facilities, these teams were closer to each other, which made it easier mutual support. The larger distances in the new building hindered collaboration and created pressure for increasing staff. This was conveyed by the head of the anaesthesia service as follows:

“In the old facility, it was the doctor in the surgical unit who helped in the postoperative area, because it was a single corridor (...) with one resident, we could do it. Now, on different floors you can’t call people for help. We needed an additional person”.

This same interviewee reported a similar drawback related to mutual collaboration between the surgical unit and the obstetrics centre. Depending on rostering, the obstetrics had only one physician, and support from the surgical staff was made difficult due to the larger distances. As a result, there has been pressure for hiring a second professional for obstetrics, although the interviewee hoped that this would eventually be unnecessary as the teams adapted to the new reality.

Interactions between the sterile and surgical units were also affected in the post-relocation. According to the head of the day surgery unit, “the first two weeks after the relocation were critical…for example, on some days we did not have gowns…the performance of the sterile unit had already been weak after their own relocated [two years earlier]”. In fact, it is well-known at the hospital that the sterile unit has faced difficulties following its own relocation, including frequent instances of late deliveries, and delivery of surgical trays with wrong or missing instruments, in addition to the hiring of a number of inexperienced employees for the new facilities.

Resilience and brittleness in the relocation process

Based on the description of the relocation process, it was possible to identify 16 instances of resilience (Table 3) and eight of brittleness (Table 4), as well as their relationships with the principles of DfRP. All principles were supported by the instances of resilience, with principle 4 (slack resources and strategies) as the most frequent, present in 37.5% of the instances. However, some slack resources are not as effective as the primary main resources, and therefore slack is often associated with principle 5 as well (acceptable performance under degraded conditions).

Table 3 Instances of resilience in the surgical unit relocation

Table 4 Instances of brittleness in the surgical unit relocation

In turn, principle 7 (learning) was enhanced by the opportunity to learn from past changes. Although these experiences were shared initially at the project relocation committee, the members of this team cascaded down this information to their coworkers during the delivery of training, enhancing the learning principle. The committee also operationalized principle 3 (standardization fit for purpose) by devising plans and schedules at a low level of detail, which would be broken down into smaller activities by sub-teams at their own units. Principle 3 was also supported by the sterile unit initiative of revising the composition of the surgical trays, which included updating the associated forms and documents.

The instances of brittleness also affected all principles of DfRP. Some of these instances were unintended consequences of resilience such as the backlog of surgeries caused by the suspension of elective procedures. Slack resources were also compromised as the large size of the new facilities made it difficult for sharing staff and materials in some areas, resulting in insufficient staff levels. Brittleness also played out in principle 1 (system modelling) as the architectural design, a key model, did not fully account for the needs of services flows, according to the interviewees. This principle was additionally hindered as there was a low attention to the development of models of logistics flows other than those related to patients. It is also worth noting that despite efforts for setting up a diverse project committee and training employees, not all hospital units were equally engaged such as the sterile unit. Thus, despite instances of principle 6 (diverse perspective) as resilience, it was also connected to brittleness.

Overall insights can be derived from the analysis of resilience and brittleness, namely: (i) resilience stemmed from formal structures such as the relocation committee, which devised policies and high-level plans that served as a basis for decentralized detailing and execution; (ii) given the large number of hospital units and staff involved, it tends to be difficult that all of them are equally engaged and perform at the same level; and (iii) the experience and knowledge of the participants in the relocation may have been underexploited due to the lack of explicit theoretical assumptions to guide this process. These assumptions could have highlighted the importance of logistics flows as well as revealed the impacts of much larger facilities. Moreover, the relocation process was short of data and tools for supporting decision-making (e.g., additional simulations of service flows, either computer-based or paper-based), which could reduce cognitive demands on the project team. Indeed, despite its diverse membership, this team could not realistically anticipate all problems, had their own biases, and unbalanced power relations.

Discussion

Table 5 lists 17 guidelines for the relocation of healthcare facilities. As explained in Sect. “Data analysis”, the guidelines emerged from the instances of resilience (R) and brittleness (B) in Tables 3 and 4, respectively. Each guideline is stated along with the instances of R and B that gave rise to them. There is a direct logical association between guidelines and instances, and all instances were linked to at least one guideline.

Table 5 Guidelines for the relocation of healthcare facilities

Table 5 also highlights the principles of DfRP supported by the guidelines and when they should be deployed (before, during, after the change). All guidelines are applicable before the change, reflecting the organizational resilience´s concern with the anticipation of challenges and the consequent adjustment of plans [40]. Twelve guidelines are applicable during the transition itself, and seven are concerned with the post-relocation period. There are also guidelines applicable across the whole relocation process. This occurs, for example, with guidelines 1, 2, and 3, which is justified by the coordinating role of the project management committee and its influence on all other guidelines.

This committee is a prime example of using principle 6 (multiple perspectives), and also aligned with recommendations of other authors for hospital relocation [36, 41]. Listening to the voice of front-line workers is a key for reducing their anxiety and uncertainty [5], as well as listening to the voice of leadership from areas such as quality, human resources, and psychology [36, 42].

Principle 4 (slack) is the most frequently associated with the guidelines (47%). This principle is crucial as the relocation inevitably implies in the operational unavailability of the areas under change, requiring temporary replacements. Slack is also important for the repurposing of clinical spaces [35], such as when postoperative and regular in-patient wards were used as intensive care units during the COVID-19 pandemic [43]. The case study indicated that this repurposing can be essential during relocation projects – e.g. day surgery area used for lung transplant.

Principle 7 (learning) underpins six guidelines, consonant with its importance to resilience. For instance, guideline 1 encourages the provision of formal organizational spaces for the exchange of experience, in line with the use of several types of reflective meetings for supporting resilience such as daily huddles [44]. Guideline 4 acknowledges that there can be key players (e.g., members of the relocation committee, in the case study) that disseminate the right information to the right people, facilitating performance adjustments [45]. Guideline 9 is concerned with training and thus it also operationalizes the learning principle, being backed by other authors [2, 35]. Guideline 5 is consistent with established notions of macro ergonomics, which stresses the move to new facilities as a unique opportunity for major changes in work organization [46]. The case study´s example of process improvement in the sterile unit is also discussed by [2] in their description of surgical unit relocation, highlighting systemic implications.

Interactions between the surgical and sterile unit can be positioned in the broader context of hospital internal logistics, which involves purchasing, moving, handling, and storing materials, equipment, information, and people [47]. As an illustration of the impacts of such logistics, the handling of medical supplies accounts for around 30% of the expenditure of hospitals, only behind personnel cost [48]. The importance of considering the logistics of both patient and supportive service flows is reflected mainly by guideline 11. In the case study, the supportive flows (e.g., clothing, waste) received less attention than the patient flows. [10] described similar problems in a hospital relocation project, in which the lack of some surgical supplies caused major delays in the patient flow.

Internal hospital logistics in relocation projects is also affected by changes in the size and layout of the new facilities [11]. At the studied unit, the implications of the 400% increase in the size of the facility were clearly perceived by all interviewees, especially regarding longer walking distances and the need for increasing the number of employees. In this respect, guideline 10 is related to staffing and addresses a common problem in hospital relocation projects [32, 33], which creates higher workload to caregivers and risks to patient safety [1, 49].

Guideline 10 also acknowledges that much larger facilities modify the technical and social interactions at the unit, creating buffers of space and time in-between teams. This reduces necessary complexity in terms of interactions beneficial to collaboration and team reciprocity, which are cornerstones of resilient systems [23]. In order to compensate for this less interactive environment, there might be a human cost in terms of extra effort of professionals and financial cost stemming from the need for hiring extra staff.

Finally, it is important to acknowledge that the uptake of the guidelines might require the allocation of substantial time from several stakeholders (e.g., unit leaders when attending the meetings of the relocation project committee, front-line workers when attending training sessions, and facilities maintenance staff when checking utilities before the relocation), which means that there are costs involved. These costs might hinder the use of the guidelines in low-resource hospitals, which are more likely to be understaffed. In such settings, possible coping strategies can involve the partial implementation of some guidelines (e.g., only representatives from the mostly clearly affected units would take part in the relocation committee) as well as the prioritization of some guidelines over the others, recognizing that not all resilient practices are equally cost-effective [50]. In addition to costs, there are other contextual factors that can affect the guidelines applicability. For example, in newer hospitals there can be no past relocation experiences to learn from, and governments (in the case of public hospitals) can pose limits to both the nature of services that can be suspended during the transition and the length of the suspension.

Conclusions

Contributions of this study

This article investigated the question of how to support resilience in the relocation process of hospital units. The surgical unit´s study exemplified why resilience is necessary in such relocation and how it manifests. It set a basis for 17 guidelines for resilient relocations, which directly address the research question. Although some of the issues underlying the guidelines (e.g., understaffed new facilities) had been described by prior works, the articulation of the guidelines forms a new coherent set of prescriptive knowledge, explicitly connected to the resilience perspective. This perspective is also new for hospital relocation. Connections with resilience principles of providing slack resources and learning opportunities stood out, respectively reflecting the need for coping with unexpected events and leveraging on the knowledge and needs of stakeholders affected by the relocation. All guidelines are applicable to the period before the change, highlighting their proactive nature.

Limitations

There are some limitations for this study. First, the guidelines stemmed from the case study of a surgical unit, and thus they tend to be more useful for this setting. However, several guidelines refer to organisational processes likely to be relevant for the relocation of other hospital units-e.g., creation of a multidisciplinary relocation committee, and learning from past relocations. Second, the hospital relocation committee did not consult patients or their representatives for decision-making, which may have implied in some missing relocation requirements and gaps in the guidelines. Third, hospital managers did not gather quantitative data regarding the before and after performance of the surgical unit, which hinders the assessment of the impacts of the guidelines. Fourth, there was no exploration of the early stages involving institutional decision-making for commissioning a new facility and developing the built environment designs (e.g., architecture). This type of investigation is challenging as hospital relocation projects usually take several years. Nevertheless, additional guidelines could have emerged provided this investigation had been conducted.

Future studies

Both the limitations and findings of this study gave rise to opportunities for future investigations such as: (i) to assess the applicability of the guidelines to other healthcare settings (e.g., private hospitals, developed countries, emergency departments), using them for the real planning of relocations; these studies can offer multiple contributions such as further detailing of the guidelines, the creation of new guidelines, and the analysis of their cost-effectiveness depending on contextual factors; (ii) to analyse patient´s perceptions of the change to new facilities, even if it is impractical to involve them as co-designers of the relocation process; (iii) to assess clinical (e.g., rate of infections) and operational performance (e.g., surgical delays) before and after the relocation, also shedding light on the learning curve after the change; and (iv) to carry out a deeper retrospective analysis of this relocation, looking back at decisions and activities that occurred much earlier than those focused on this article.