Healthcare Project Management 101: Experts Share Techniques, Examples and Future Outlook

By Kate Eby | February 6, 2020 (updated September 16, 2023)

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This article provides a wide range of details about healthcare project management (PM), along with tips from experts on how to perform it well. You’ll also find details on project management techniques, including Agile and waterfall, and information on a career as a healthcare project manager.

Included on this page, you'll find details on what healthcare project management is , Agile project management in healthcare , why project management is important in healthcare , and information on what it takes to be a healthcare project manager .

What Is Project Management?

Project management is a process of planning, organizing, and overseeing the work of a team to advance a specific organizational project and achieve an organization’s objectives. Project management does not involve the routine day-to-day operations of an organization. 

Instead of focusing on everyday duties, PM zeroes in on work with a defined end point and a specific goal. Project management occurs in a wide range of industries and organizations, including healthcare organizations. You can learn more about project management with this project management guide .

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Ready to get more out of your project management efforts? Visit our comprehensive project management guide for tips, best practices, and free resources to manage your work more effectively.

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What Is Healthcare Project Management?

Healthcare PM concerns any projects that seek to improve the functioning of a healthcare-related organization. As the industry continues to evolve, there are increasing pressures to save money and be efficient while improving the quality of patient care.

All of that means that hospitals, healthcare systems, and others in the industry are continuously executing projects to improve their operations.

Teresa Knudson

“Now more than ever, healthcare really needs to adopt [good project management principles] because of all the internal and external challenges,” says Teresa Knudson , Director of the Enterprise Portfolio Management Office at the Mayo Clinic and a board member of the nonprofit Project Management Institute (PMI). “You have to know what you’re doing and be better at it.”

Waterfall Project Management in Healthcare

The waterfall methodology is one of the most common methodologies in project management. It organizes the project in a sequential and linear process (flowing like a waterfall) and has a number of phases. A new phase can’t begin until the prior phase has been completed.

The waterfall methodology has often been used in manufacturing and construction. And, healthcare construction projects are often managed through the waterfall project management methodology. For example, a hospital needing to build a new cardiac catheterization laboratory suite will have defined requirements and a timeline commencing at the onset of the project. The hospital may also have built similar projects before. The project lends itself to the waterfall method because there are defined phases that need to be accomplished linearly.

Greg Githens , an executive and leadership coach and the author of How to Think Strategically , also points out that some healthcare projects that may require eventual Food and Drug  Administration (FDA) approval — the creation or development of a medical device, for example — may significantly benefit from the waterfall methodology. That’s because the FDA, along with other government agencies, require quality checks and design checks at various stages of development that are easier to document in waterfall, he says.

“You have to have testing along the way and a lot of documentation to support your testing,” he says. “Waterfall basically means that you move in phases and that you don’t exit a phase until you can check off all the boxes that indicate that you’ve finished all the required work.”

You can learn much more about the waterfall methodology from this guide on the waterfall methodology .

Agile Project Management in Healthcare

Agile project management began in software development. It employs a much more incremental and continually evolving approach than waterfall. It uses a cyclical process that encourages flexibility, experimentation, and adaptability.

The Agile methodology can work better than waterfall for many healthcare projects because healthcare work and processes can have numerous and constantly changing variables. Agile can help healthcare project management teams easily adjust to those changes.

“The iterations [of a process change] in Agile are shorter,” says Githens. “One of the advantages is that you’re able to recognize a mistake earlier and then correct that mistake.”

You can learn more about Agile from this guide on the Agile methodology .

A Hybrid Approach — A Combination of Waterfall and Agile

Healthcare project management teams sometimes use a hybrid approach, employing a combination of waterfall and Agile to manage a project.

In these circumstances, teams may primarily use the Agile methodology, while at the same time incorporate some aspects of waterfall to provide a timeline and a project roadmap to team members and to an organization’s leaders.

Why Is Project Management Important in Healthcare?

Project management has become even more important in healthcare in recent years. In large part, that’s because of safety concerns: a healthcare project done ineffectively can lead to patients’ health problems.

But, a range of other issues are affecting the evolving industry — issues for which project management is increasingly vital. These issues include the following:

  • Decreasing payments from government health programs and private insurance companies have compelled healthcare organizations to find ways to save money.
  • New and complicated systems for electronic health records on patients need continual monitoring and improvement.
  • New technologies also need tracking and improvement.
  • New regulations continue to emerge.
  • There is greater scrutiny from outside groups, including government, health insurance companies, and patients.

The Huge Costs of Healthcare, the Size of the Industry, and Issues with Safety

A range of statistics indicate the enormous size of the healthcare industry and its effect on the overall economy and the life of Americans. These stats also underline the amount of work that healthcare organizations require for project management to continually improve operations in such a huge industry:

  • Americans spent $3.5 trillion dollars on healthcare in 2017, or $10,739 per person. That compares to $3 trillion in 2014 and $2.6 trillion in 2010. For comparison, Americans spent $247 billion on healthcare in 1980.
  • After the passage of the Affordable Care Act in 2010, the rate of people without health insurance had dipped to 9.2 percent by 2015.
  • Nearly five million doctors and nurses work in the U.S.
  • Experts predict that the industry will add another 3.4 million healthcare jobs by 2028.
  • Eighteen of the 30 fastest growing occupations in 2018 were in healthcare.

Meanwhile, the healthcare industry has significant problems with safety and with deaths from medical errors:

  • A 2018 Johns Hopkins study estimated that more than 251,000 people in the U.S. die annually from medical errors.
  • A 2012 report by the National Institutes of Health estimated that 440,000 deaths in the U.S. per year were from medical errors.
  • Some studies have estimated that medical errors affect as many as one in three patients.

Benefits of Healthcare Project Management

Strong project management helps improve healthcare and the healthcare industry in a number of ways. Project management can do the following:

  • Improve the quality of care by improving processes used to provide that care.
  • Improve communication among healthcare staff caring for patients.
  • improve organizational planning.
  • Improve budgeting, as strong project management directly aligns resources with important work.
  • Increase staff productivity.
  • Improve processes that are established to decrease the risk of lawsuits — in large part because improved processes increase the quality of care.
  • Improve relations with stakeholders, including insurance providers, government agencies, patients, and others.

Challenges of Healthcare Project Management

The healthcare industry can present special challenges to good project management. Here are some of those challenges:

  • There are high stakes. Poorly executed projects can bring more serious ramifications, because patients’ health can be at stake. “Patients’ lives are a part of this,” says Githens. “A poorly done project might end up with poor healthcare outcomes.”
  • There are continually rising costs in the industry.
  • There is heavy governmental regulation.
  • Healthcare is a continually evolving industry.
  • There is a high risk of lawsuits.
  • There is a broad array of involved stakeholders, including hospital boards, medical providers, state and national governments, and patients.
  • There is skepticism among some important stakeholders about the importance of project management. Medical providers who are highly accomplished professionals in a particular medical speciality “sometimes see project management as a non-value-added administrative function,” Githens says.

Why Healthcare Project Management Fails

Managing projects in a wide range of industries can be complex, and those projects sometimes fail. But, healthcare project management can be even more complex and may fail even more often. 

In fact, according to the book, Project Management for Healthcare Informatics, one study estimated that as many as 80 percent of healthcare projects fail . 

These failures happen for a range of reasons. Here are some of the most common ones:

  • Lack of Prioritization: Any organization could embark on hundreds of “projects” at any time. But, embarking on too many projects means an organization is not doing any of them well. Overcommitting is not an efficient use of resources, and it’s not effective. “Most organizations have way too many projects, and the projects are therefore under-resourced. [The organizations] are doing a ‘squeaky wheel gets the grease’ prioritization process. They’re trying to do too much and not setting priorities for the organization.”

Greg Kain

  • Poor Definition of Project Requirements: Making mistakes, such as misunderstanding and inaccurately defining project requirements and goals, is an integral part of planning. However, these mistakes during planning can create major problems beyond the planning stage. When team members don’t ask the right questions about the goals of a project, they don’t realize that reaching the stated goal won’t really improve the organization.“ The number one reason for project failure is poor requirements or incomplete and incorrect requirements,” says Githens. A lack of serious analysis means the group “puts a solution in place that’s not the right solution,” he adds.

According to that study (above) cited in Project Management for Healthcare Informatics, here are some additional reasons for project failure in the healthcare industry:

  • The growing complexity of data collection requirements in healthcare organizations
  • Increased regulation
  • Poor communication among a healthcare organization’s leaders, stakeholders, and patients
  • Organizational resistance to change

Examples of Healthcare Project Management

Project management is used in thousands of cases in the healthcare industry. Projects may seek to improve patient care, improve efficiencies or save money, or improve other parts of an organization’s operations. Below are some examples of healthcare project management.

Improving Patient Care and the Patient Experience

Here are some examples of healthcare project management concerning the improvement of patient care and the patient experience.

  • Improving the Patient Experience from Hospital Admission to Discharge: Hospitals are increasingly analyzing the patient experience from the moment a patient arrives at a facility (either as an in-patient or outpatient) to the moment they leave, Githens says.
  • Developing a Template for Approval to Use an Air Medical Helicopter to Land at a Medical Facility: “Project Management for Healthcare,” a white paper written by David Shirley, a project management consultant and college professor, cites a case where an air ambulance service was approving the landing of its helicopters at specific facilities on a case-by-case basis. “Because the requirements were standard — distance from the buildings, size of the landing area, approach procedures, etc. — it was logical to undertake a project to build a template that only needed to be tweaked for a medical facility’s request,” Shirley wrote. “Developing the template reduced the approval times, thus potentially saving lives.”
  • Increasing the Size/Number of “Safe Rooms” in a Psychiatric Facility: A facility determined that it didn’t have adequate areas to care for and monitor agitated psychiatric patients and keep them from self-harm. A project helped design, plan, and build a safe room.
  • Designing an Improved Hospital Gown: A project helped design a hospital gown that was easy and comfortable for patients to wear and that met the needs of doctors who were examining patients.

Improving Operations

Here are some examples of healthcare project management concerning the improvement of operations.

  • Improving Administrative Efficiencies: This includes insurance processing.
  • Improving Efficiency of Temporary Health Worker Payment: A healthcare organization found that most of its invoices from temporary workers were incorrect in some way and routinely needed revision. A project helped design a standard invoice and invoice process that reduced errors.
  • Improving Efficiency of Operating Room Use and Improving Consistency in Operating Room Start Times: A hospital found that it had delayed start times for daily operating room use, often 30 minutes or more after the scheduled start time of 8 a.m. The hospital instituted a project that set up processes to address the various reasons for the delays — including how the organization prepared patients, staffed operating rooms, and kept surgeons apprised of surgery schedules.
  • Maintaining a Hospital Facility: A project addressed how a hospital informed its maintenance department of mechanical breakdowns and how that department responded to those breakdowns.

Other Projects

Here are some other examples of healthcare project management.

  • Electronic Health Records: Hospitals are routinely embarking on projects to adjust and improve the information technology systems that store and allow access to patients’ electronic health records.
  • Sharp Injuries to Hospital Staff — such as Skin Pricks from a Dirty Needle: These incidents are a major issue for hospitals. Such occurrences can and do expose hospital staff to dangerous viruses, including the human immunodeficiency virus and the hepatitis B and C viruses. One hospital embarked on a project to reduce sharp injuries in the hospital’s operating rooms.

Areas in Healthcare Ripe for Good Project Management

Project management is used in a wide range of areas within healthcare organizations. But, there are particular areas where it’s especially helpful. They include the following:

  • Information Technology: This includes managing all data and patient records and is beginning to include artificial intelligence systems.
  • Facilities: This relates especially to construction, renovations, and facility upgrades.
  • Process Improvement Projects: These are often focused on specific processes or procedures in order to cut costs or reduce errors when providing care to patients.

Healthcare Tasks That Project Management Can Help Guide More Efficiently

Project management can help improve processes across broad categories of work in healthcare organizations. Well-executed projects can help improve some of those day-to-day processes. Areas where they can help include the following:

  • Managing Tasks: The work of many health care specialists is dependent on the work of others. Some tasks must be completed before other tasks can begin. Project management can help improve systems and processes to ensure that they are operating as efficiently and effectively as possible.
  • Managing Staff Time: Having the appropriate health care staff available at the right time is essential for providing quality care. Project management can help ensure appropriate scheduling and time management for all staff members.
  • Managing Resources: Project management can ensure that your healthcare organization is effectively and efficiently allocating the resources it needs to do its job.
  • Managing Change: Employees in many industries — including the healthcare industry — resist change. Project management can help communicate and implement change in a way that leads to less resistance from staff.

Tips For Effective Healthcare Project Management

Experts offer a range of tips that can help your organization execute good project management. Top tips include the following:

  • Communicate openly with the entire organization about projects and goals.
  • Set up an appropriate governing structure to oversee the project. That means a structured system of rules and processes that help move the project forward. “The governance model is critical,” says the Mayo Clinic’s Knudson. That should include determining who to assign to important roles in the project. “Who’s the champion? Who’s going to be there day in and day out like a parent — there to solve issues?”
  • Prioritize. Decide which projects are vital and which shouldn’t be projects at all. “Resources are limited, whether human or financial,” write the authors of Project Management for Healthcare Informatics. “And, some organizations are unable to accomplish all the projects they want in a given time frame. The information an organization gathers during [a project’s initiation] phase … helps senior leadership make an educated decision on which projects should continue.”
  • Set up the right team. Ensure that your team includes employees from across the organization who understand the process that the project is trying to improve. “You want to make sure that you have the right team members,” says Knudson. “And often, that means bringing together people who’ve never worked together. [Leaders need to] get everybody working together toward that same common goal. They need to assign the right responsibilities to the right team members.” “I really focus on having that high-performing team,” Knudson says. “And, we all respect one another’s roles.”
  • Create and follow the project charter and scope document. Integrated Project Management Company’s Kain says that when his group is pulled in because a healthcare organization’s project is in distress, “It’s almost always the case that there isn’t a good charter.” Without a good charter, “you lose alignment regarding why you’re doing the project to begin with,” Kain says.
  • Ask the right questions about project requirements and goals. Githens says that at the beginning of a project, the project team members need to ask probing questions about the project’s requirements, such as “What is it trying to accomplish?” and “What does success look like?” “The number one reason for project failures is poor requirements,” Githens says. “Once you realize that, you know you have to be more proactive and ask better questions” at the project’s onset. In order to avoid project failures, make sure to do the following:
  • Streamline the process as much as possible.
  • Expect the unexpected and be willing and able to adapt.
  • Document your results.
  • Understand healthcare regulations and governance and how they impact the process and your project.
  • Create a project management office. Organizations are increasingly creating internal departments, or enlisting an external group, to define and maintain the organization’s project management standards.

Healthcare Project Manager Job Description

A healthcare project manager is responsible for leading and overseeing projects that a healthcare organization is pursuing to improve operations or patient safety. The manager coordinates and directs all project team members working on the project.

What It Takes to Be a Healthcare Project Manager

Being a good healthcare project manager takes some specific skills, including the ability to approach and react to problems.

Here are some basic skills required of project managers:

  • Interpersonal skills to help you work with and inspire a range of organizational employees 
  • Leadership skills
  • Problem-solving skills
  • The ability to be flexible and adjust to changing circumstances

You also need to develop a nuanced understanding of the following:

  • Working in an unusual market, where insurance coverage and other variables make the buyer and seller relationships different than in many markets
  • How a range of healthcare stakeholders will want to be involved in many projects
  • The increased regulation of the healthcare industry

Education that you will or may need includes the following:

  • Undergraduate degree related to health administration, public health administration, nursing, economics, or business administration
  • Advanced degree in similar fields

Knudson, from the Mayo Clinic and the Project Management Institute, says she believes that there are some overall attributes that strong healthcare project managers should have.

“You’ve got to love change,” she says. “You’ve got to love challenges. We’re impacting patients’ lives. We’re helping patients. Healthcare PMs are ultimately serving the patient. I think you need people who are really motivated by that idea.”

She says she likes healthcare project managers “who jump in and figure out how to solve things. People who will jump with me into the deep end of a pool without knowing how deep it is.”

Healthcare Project Management Training

Beyond their undergraduate or graduate degrees, many project managers take part in ongoing training to improve their skills and gain certain certifications in project management.

The Project Management Institute, a nonprofit professional organization of project managers around the world, awards specific certifications in project management. PMI certifications include the following:

  • Project Management Professional (PMP)
  • Program Management Professional (PgMP)
  • Certified Associate in Project Management (CAPM)

Some healthcare project managers also have certifications in various healthcare disciplines and specialties.

How Much Do Healthcare Project Managers Make?

Some groups have estimated that the average annual salary of a healthcare project manager runs from about $79,000 to $91,000. A 2017 biennial survey conducted in part by the Project Management Institute found that the average salary of healthcare project managers was higher than that — about $112,000. About 33,000 respondents in 37 countries participated in the PMI survey.

The Job Outlook for Healthcare Project Managers

The job outlook for healthcare project managers is very good.

In a 2017 report, the Project Management Institute estimated that an average of 2.2 million new project management roles would need to be filled by employers each year from 2017 through 2027. That growth will be fueled in part by a high number of current employees retiring. While the report covered project managers in all industries, it also indicated that project management needs in healthcare were expected to grow especially fast.

Meanwhile, the U.S. Bureau of Labor Statistics has estimated that employment of medical and health services managers — of which project managers is a part — is expected to increase 18 percent from 2018 to 2028. That’s much faster than the average for all occupations.

Project Management in Public Health

Project management is increasingly used in public health initiatives. These initiatives often need to provide information to the general public and find ways to interact with the general public.

The type of public health work where project management might be relevant includes the following:

  • Vaccination and immunization programs
  • Outreach about telemedicine programs available through healthcare organizations
  • The establishment or adjustment of policies for governmental health programs
  • The creation or adjustment of programs to prevent communicable diseases

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A Guide to Hospital Administration and Planning pp 1–24 Cite as

Hospital Designing and Planning

  • Himanshu Bansal 6 , 7 ,
  • Riya Mittal 7 &
  • Vijay Kumar 8  
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For constructing an efficient hospital, we require some guiding principles and to go through a series of phases in planning and designing of hospital. Principles and phases to be followed are selection and purchase of the site (land); early employment of the architect; functional and operational plan prepared before the architectural plan; schematic designing and drawing of initial and rough outline; preliminary allocation of the spaces and room layouts; construction documents for estimating costs; planning of construction activities; planning of mechanical, electrical, and plumbing services; construction of hospital building step-by-step; working out the requirement, configuration, and technical specification of equipment; planning of manpower; finalizing the SOPs, rules and regulations, rate list, etc.; and testing of equipment. Services, training of staff, and disinfection of hospital should be ensured before the opening of the hospital. Hospital must be planned for the future. Do not hurry up the planning stage. Every detail should be complete. Planning and design of hospitals generally use benchmarks and experience without rigorous analysis of processes, resources, and facility requirements. Building a hospital is one of the most complex projects to plan, design, and build, and quality of planning and designing has a long-term impact on the performance of the hospital. Once planned and designed, the project is executed in different phases as discussed above.

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Everything you need to know about healthcare project management (& how to master it)

Trello

Today’s companies in the health and wellness space are plagued by rising costs, staffing issues, and increasingly strict regulation that makes it difficult to keep the lights on—much less thrive. As a result, healthcare teams are under incredible pressure to maximize resources, reduce overhead, and adopt effective project management systems. 

The ability to plan, manage, and successfully execute projects has a direct impact on your org’s reputation, bottom line , and employee morale. But the stakes are even higher for healthcare project management, where projects and initiatives directly impact patient care.

Great healthcare project management doesn’t happen by chance. It requires a deep understanding of what you want to accomplish, a framework for how to execute that vision, and the right tools to guide you through to completion. Here’s how to get started.

What is healthcare project management?

Healthcare project management refers to the organization, planning, and execution of a particular project and its resources. Through project management, healthcare organizations take a project—like building a new hospital wing—from initial inception all the way to completion to achieve desired outcomes. 

The four primary stages of healthcare project management:

Stage 1 – initiation.

During this phase, stakeholders review potential projects and evaluate goals, resources, and expected outcomes to determine which are worth approving—and which should be tabled. This is a critical stage for healthcare organizations, which are often working with limited budgets or resources and need to prioritize projects with the highest potential impact. 

For large hospitals, that might be trying to invest in new facility construction depending on changes in patients served or new treatments or technologies developed. For fitness studios, it might be trying to determine which equipment to order or new staff to hire.

Stage 2 – Planning

Once a project has been approved, it moves into the planning phase. In this stage, the project manager creates a detailed project plan that outlines logistical elements like the schedule, tasks, budget, project contributors, and contributor responsibilities. 

Additional items to consider at this point are potential challenges that may arise and how the success of the project will be measured. The goal of this phase is to obtain all the decisions necessary to move on to the execution phase, such as conducting a facility needs assessment with key hospital administration and staff, or obtaining total costs of new gym equipment.

Stage 3 – Execution

The execution phase is where the rubber meets the road. In this phase, project contributors carry out their designated tasks and work toward completion of the project. It’s vital that teams effectively track, measure, and communicate their progress throughout the entire execution phase.

This allows the project manager to identify roadblocks, reallocate resources, and make adjustments to keep everything on track. For example, ensuring that the hospital wing construction documents are submitted to the proper regulatory channels for building permits or placing orders to gym equipment manufacturers.

Stage 4 – Conclusion

Once the project has been completed, it’s time to wrap everything up. In the conclusion phase, the project manager provides stakeholders with a summary of how everything went, along with any key deliverables and results. This is a great time to reflect on what went well, which areas could be improved for future projects, and how each project contributor performed. 

Applying this stage to the previous hospital construction example mentioned above, this conclusion phase would consist of final inspection and gaining input from patients or staff who use the new facility and equipment daily after opening.

Each project management stage builds off the previous one and is critical to your project’s overall success. By dedicating time to all four stages rather than focusing solely on one or two, healthcare practices can increase the likelihood of a positive project outcome.

Methodologies for healthcare project management

Every healthcare company has projects, but the way they manage them can vary dramatically. Some orgs prefer a more flexible approach to project management, while others require a system that’s more structured. That’s where project management methodologies come in.

A project management methodology is a guiding framework that determines how you, as a practice, plan and execute your projects. Most healthcare companies use one of three methodologies to steer their efforts: the waterfall methodology, the agile methodology, or the hybrid methodology.

Waterfall project management

The waterfall project management methodology is a sequential, linear model in which projects are broken down into smaller, defined phases. Each phase is mapped out in extraordinary detail with tasks, deliverables, and deadlines and must be completed before the next phase can begin. 

With the waterfall method, the entire project is visually laid out from start to finish (often in a Gantt chart like the one featured below). This makes it easy for stakeholders to gauge the full scope of the project, see who’s involved, and get a realistic idea of how long each phase is expected to take.

Screenshot of a waterfall project displayed on a Gantt chart

Use Gantt charts for waterfall project management 

It’s a rigid system, but it works well for teams that have large, complex projects with multiple stakeholders involved—like those who work in public health. 

Agile project management 

The agile project management methodology is an iterative model that’s centered around speed, communication, and adaptability. Teams complete various phases of the project in parallel rather than taking a sequential approach to execution, relying on collaboration and communication to keep everything on track.

Let’s say your practice just started offering a new interventional radiology procedure and needed to add a landing page to your hospital’s website so you can increase awareness. Under an agile approach, your webmaster could start mocking up the page design while a radiologist reviews the final copy instead of having to wait to get started. When that copy does get approved, the page is already designed and ready to launch. 

Agile projects are often laid out in a Kanban-style board , with emphasis placed on task status versus deadline/assignee. Everything that needs to be completed lives in a “To Do” section, and tasks that have been started are denoted as “Doing” or “Done” so everyone knows what’s in progress.

Mockup of a Kanban board that displays a project sprint

Use Kanban boards for agile project management

It’s a much more flexible approach to project management—one that benefits teams at healthcare startups or smaller practices where there’s pressure to knock projects out quickly. 

Hybrid project management

The hybrid project management methodology balances the flexibility and speed of the agile method with the big-picture planning of the waterfall method. 

Let’s say your team wants to upgrade to a new electronic medical records (EMRs) system by the end of Q4. You could incorporate waterfall elements during the initiation and planning phases of the project, creating a detailed roadmap that outlines the steps, deadlines, and resources necessary for completion. This higher-level overview is often necessary to get leadership buy-in and can help keep teams on track when the project gets rolling.

Once the project moves into the execution and conclusion phases, however, you’ll want to take a more agile approach that enables teams to tackle various phases of the project simultaneously.

In this scenario, there’s an outline of what needs to be accomplished, but teams still have the flexibility to adjust timelines, re-prioritize items, and adapt to changes as needed. This more flexible approach can keep projects from getting blocked and help teams meet (or beat) their deadlines. 

The impact of great project management 

Orgs with effective project management processes in place can benefit from improved patient outcomes, better systems, and lower costs.

When done correctly, healthcare project management can help organizations improve a number of areas, including:

  • Internal processes. With a defined project management system in place, you can standardize how teams approach every aspect of a project—from initiation all the way to completion. This ensures consistency and makes it easier to identify (and improve) parts of the process where projects consistently break down. 
  • Organizational planning. To truly excel at project management, an emphasis on planning is required. Project contributors, managers, and stakeholders must train themselves to think with a big picture in mind and get comfortable mapping out a project step by step. That planning mindset carries over into every other aspect of the organization—from scheduling to ordering important medical supplies —and can positively impact the quality of care.
  • Stakeholder relationships. Orgs can strengthen relationships with their board of directors, volunteers, and donors by involving them in the project approval phase, providing regular updates about project status, and communicating wins. With a system in place to track project completion and success, it’s also easy to demonstrate value by quantifying the number of changes your company has made—and their impact.

Healthcare companies without a defined approach to project management may find themselves battling inefficiency, burgeoning costs , and high litigation/regulation risk. 

5 best practices for healthcare project management

There’s no one-size-fits-all approach to healthcare project management. The way you choose to approach project management can vary based on your organization’s structure, your preferred methodology, the type of projects you manage, and other factors.

With that being said, there are a few simple steps you can take to improve project management within your healthcare practice.

1. Invest in a secure project management tool

Many companies rely on a project management tool to help them organize, track, and manage their projects. For companies in the healthcare industry, it’s not enough to find a project management solution with flashy features. You’ll need a secure tool (like Trello Enterprise ) that enables your teams to manage projects more efficiently and protects their data. 

Here are security features to look for when choosing your healthcare project management tool:

  • SOC2 compliance . This independent auditing procedure evaluates a tool’s ability to manage customer data in five key areas: availability, processing, security, confidentiality, and privacy. In short, it’s a strong indicator of whether or not that project management tool can protect your data. As a general rule of thumb, if it’s not SOC2 compliant, you probably shouldn’t use it. 
  • Login security. According to IBM’s Cost of a Data Breach report, compromised credentials were the top source of data breaches in 2021. It’s essential that whichever tool you select offers features that add an extra layer of security when employees log in, like single sign-on (SSO) and two-step verification (2SV). 
  • User management. On any given day employees can resign, move into a new role within the company, or transition departments. And as these changes occur, you need to be able to quickly adapt employees’ permissions. Trello offers automated user management through Atlassian Access and automatically updates employee permissions based on changes within your employee directory. 
  • File-sharing restrictions. Your project management tool will house all your project files, attachments, and resources—but you may not want everyone to be able to see them. Be sure the tool you select offers file-sharing restrictions so that only need-to-know users can access sensitive project documents. For example, Trello uses authenticated attachments to ensure that no unauthorized users can access files shared on your project cards or board.

2. Pay proper attention to planning

Insufficient planning is a huge contributor to project failure . Before you start working through specific tasks, take the time to create a project charter that defines your project’s goals, resources, key deliverables, and metrics for success. If you’re upgrading the cardio equipment at your fitness center, explain why the project is important, outline who should be involved, and specify any expectations you have regarding deadlines, communication, etc. 

This planning document will be critical in ensuring that the entire team (and your stakeholders) are aligned on the goals and logistics of the project.

Once you’ve finalized your project charter, make sure it’s easily accessible to all the project contributors. If you’re using Trello for project management, you can add the charter directly to the resources list on your project board so team members can refer back to it.

Screenshot of a cardio equipment upgrade project board in Trello, with a project charter document added to the resource section

Attach a project charter to your Resource board for easy access

3. Prioritize your projects

Many healthcare companies have to balance limited resources and staff shortages when managing projects. In order to maximize your team’s efforts, it’s important to differentiate projects that need to be completed ASAP from those that aren’t as pressing. You can do that by assigning priority levels to each project—and encouraging contributors to focus on high-priority projects. 

You can choose to prioritize projects based on deadline, urgency (e.g., a project that’s not time-sensitive but is important to stakeholders), or the perceived impact of the project outcomes. Whichever method you choose, you’ll need to find ways to clearly communicate priority levels to your project team. 

If you opt for a deadline-based approach to project prioritization, Trello’s Timeline view is a great resource. Through the Timeline view, teams can visually track and manage multiple project timelines all in one place. This allows them to see which projects have approaching deadlines, visualize how tasks fit together, identify potential overlap issues, and adjust the tasks they need to prioritize accordingly.

Picture of a several healthcare projects displayed through Trello’s Timeline view

Use Trello’s Timeline view to manage deadlines and prioritize projects

For teams that take a mixed-bag approach to project prioritization, labels make it easy to visually tag individual tasks with priority levels. You can designate project items as “High Priority,” “Medium Priority,” or “Low Priority,” and even create custom labels that note whether each task is “Urgent” or “Not Urgent.” This encourages contributors to focus their efforts on high-priority, high-urgency items over tasks that aren’t as pressing.

Picture of a Trello card being tagged with custom labels to indicate priority level

Use custom labels to indicate task priority and urgency

4. Make it easy to work together across departments

Sometimes projects are confined to individual teams, but more often than not, larger projects within your healthcare facility require contributions from employees in a number of departments. If those teams can’t collaborate with each other, important project information can get siloed within departments and cause delays. 

Lean heavily on your project management tool to simplify the collaboration process and help everyone work together—regardless of department.

Trello enables cross-team collaboration by providing a centralized location where all project resources, updates, and deliverables can be accessed. Employees can easily check task statuses, request feedback from other contributors, and share files between departments.

Screenshot of a Trello card with an advanced checklist, where an employee left project updates for a team member

Trello makes it easy for teams to collaborate on projects

Instead of each team working on their portion of the project as an independent unit, Trello enables them to work together through the same tool. This helps increase visibility and enables collaboration.

5. Remember that communication is critical

Effective communication is key to the success of any project—especially if your team has taken an agile approach to project management. At any given time, project contributors may need to collectively brainstorm solutions to a challenge, share updates with stakeholders, or communicate their needs to other team members. If they can’t, the entire project could break down.

Trello makes it easy for teams to enhance their communication—both internally and with external stakeholders. Employees can tag team members into conversations on various project cards and use the comment section to request resources, ask questions, or provide additional context about a task. 

You can even use Power-Ups (i.e., integrations) to connect your org’s other communication tools (like Slack and email) to Trello. That way, instead of navigating out of the platform to send a project update to stakeholders, you can initiate those conversations directly within Trello

Screen Shot 2022-08-10 at 4.25.03 PM

Master healthcare project management with Trello Enterprise

Whether you’re a large hospital, a small private practice, a biotech company, or a wellness provider, Trello makes it easy to plan, track, and manage projects of any size. Our platform is packed full of flexible features that support clinical operations and empower healthcare teams to save time, reduce overhead, and improve the way they work.

Health and wellness orgs across the globe use Trello to: 

  • Track procedures
  • Manage equipment and inventory 
  • Improve vendor communications 
  • Streamline onboarding
  • Connect healthcare teams across departments
  • Collaborate on medical research and publications
  • Balance staff workloads and organize schedules

Find out how you can do the same.

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Hospitals and Health Centers: 50 Floor Plan Examples

project hospital planning

  • Written by Fabian Dejtiar | Translated by Zoë Montano
  • Published on August 17, 2018

A floor plan is an interesting way to represent and approach the functional program of hospitals and health centers, where the complexity of the system implies the need for specific studies of the distribution and spatial organization for proper health care.

From our published projects, we have found numerous solutions and possibilities for health centers and hospitals depending on the site's specific needs.

Below, we have selected 50 on-site floor plan examples that can help you better understand how architects design hospitals and health care centers.

Maggie's Cancer Centre Manchester / Foster + Partners

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Hospital Complex Broussais / a+ samueldelmas

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Livsrum - Cancer Counseling Center / EFFEKT

project hospital planning

Villa el Libertador Príncipe de Asturias Municipal Hospital / Santiago Viale + Ian Dutari + Alejandro Paz

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Municipal Healthcare Centres San Blas + Usera + Villaverde / Estudio Entresitio

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San Jerónimo Hospital Refurbishment / SV60 Arquitectos

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Villeneuve-Saint-Georges Hospital / Atelier d’architecture Michel Rémon

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Psychopedagogical Medical Center / Comas-Pont arquitectos

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D’olot i Comarcal Hospital / Ramon Sanabria + Francesc Sandalinas

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Sant Joan de Reus University Hospital / Pich-Aguilera Architects + Corea & Moran Arquitectura

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Angdong Hospital Project / Rural Urban Framework

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Hospital de la Santa Creu i Sant Pau / Silvia Barbera Correia + Jose luis Canosa + Francisco Rius + Esteban Bonell + Josep Maria Gil

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Dronning Ingrids Hospital / C. F. Møller Architects

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Cerdanya Hospital / Brullet Pineda Arquitectes

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El Carmen Hospital Maipu / BBATS Consulting & Projects + Murtinho+Raby Arquitectos

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Hospital Tierra De Barros / EACSN + Junquera Arquitectos

project hospital planning

Nuevo Hospital Universitario La Fe de Valencia / Ramon Esteve, Alfonso Casares

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Kangbuk Samsung Hospital / Hyunjoon Yoo Architects

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Hospital Campus de la Salud / PLANHO + AIDHOS arquitectos S.A.

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Hospital of Sant Joan Despi Doctor Moises Broggi / Pinearq + Brullet-De Luna Arquitectes

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Nemours Children’s Hospital / Stanley Beaman & Sears

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Vall d’Hebron Hospital / Estudi PSP Arquitectura

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Hospital of Mollet / Corea Moran Arquitectura

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Hospital General de la Línea de la Concepción / Planho Consultores

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Subacute Hospital of Mollet / Mario Corea Arquitectura

project hospital planning

Hisham A. Alsager Cardiological Hospital / AGi Architects

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New Lady Cilento Children's Hospital / Lyons + Conrad Gargett

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The Christ Hospital Joint and Spine Center / SOM

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Fundación Santa Fe de Bogotá / El Equipo de Mazzanti

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Hospital General de Níger / CADI

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Nelson Mandela Children's Hospital / Sheppard Robson + John Cooper Architecture + GAPP + Ruben

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NGS Macmillan Unit / The Manser Practice

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Rocio's Hospital / Manoel Coelho Arquitetura e Design

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Healthcare Center in Valenzá / IDOM

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Urban Hospice / NORD Architects

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Legacy ER Allen / 5G Studio Collaborative

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Advocate Illinois Masonic Medical Center / SmithGroup

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Kraemer Radiation Oncology Center / Yazdani Studio of CannonDesign

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Nozay Health Center / a+ samueldelmas

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Health Municipal Clinic / studiolada architects

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Bridgepoint Active Healthcare / Stantec Architecture + KPMB Architects + HDR Architecture + Diamond Schmitt Architects

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Asahicho Clinic / hkl studio

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Health Clinic Ruukki / alt Architects + Karsikas

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Medical Centre Cortes / Iñigo Esparza Arquitecto

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Healthcare Center in Tordera / Carles Muro + Charmaine Lay

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Primary Care Center / Josep Camps & Olga Felip

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Urban Day Care Center for Alzheimer Patients / Cid + Santos

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Health Center in Oleiros / Abalo Alonso Arquitectos

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A Parda Health Centre / Vier Arquitectos

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Centro de Salud de Quintanar del Rey / MBVB ARQUITECTOS

project hospital planning

  • Sustainability

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project hospital planning

Project Hospital

project hospital planning

Originally posted by Borobej : I agree, a simple wall/object layout would be nice. But look at it this way - mistakes are costly in real life, so it's good that a "simulator" shows that. ;)
Originally posted by Borobej : Hey, you're the one building your hospital so it's your mistake, not the game's. :)

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Hospital Architecture Design & Planning

hospital architecture design & planning india

Introduction

Planning the Design and Construction of Healthcare facilities is a very specialised field that has begun getting its due only in the last few years in India. This is because we have now come to realize the important role the design and planning of the hospital plays in healing the patient. The aim of an architect is to ensure that their design satisfies the people living and functioning in the space they design. In a hospital this includes the Doctors, Nurses, Staff and of course the Patient. The design of a hospital must meet all their requirements. It is therefore the Architect’s duty and responsibility to design accordingly. Patient Care guides our Healthcare Design. Their safety and quality of care is the aim of all our Architects, Planners, Quality Consultants and Project Managers.

How Accreditation brought in change to the field of Hospital Design

NABH Standards Hospital Design

The scenario began to change with the advent of Healthcare Accreditations like the NABH & JCI and Consultants like us, specialising in the field. Vast experience in the area of Quality Accreditation helped us understand the requirement for specific infrastructure to meet the NABH & JCI requirements and that looking into these aspects right from the healthcare facility planning and layout stage was not just important but mandatory. Right from designing the widths of the staircases and corridors, planning the layouts of areas like the Operation Theatres and Critical Care Units, to providing the required space between Beds in the Wards and even locating the Nursing Stations etc., we saw how almost all areas of the Hospital needed to be designed with regard to meeting the Patient Safety requirements of the Accreditation Standards.

Hospital Architecture Design & Planning

As Hospital Architects and Designers our role is to help improve patient outcomes at the Hospital by preventing spread of infections and being able to send patients home faster. We need to ensure through our Hospital Design that there is proper infection control through better Planning & Layout of the Facility ensuring better Patient & Staff Flow and controlled air movement. In addition to Patient Safety, other aspects, as Hospital Planners and Designers we help make all areas of the Hospital Accessible and Patient Friendly, a very important contributory factor in improving outcomes.

Designing Patient Friendly Healthcare Facilities

Hospital Design Guide

Designing a Lean Hospital

Hence the Importance of having Hospital Architects to be Qualified and Experienced specifically in the field of Healthcare

Major Elements in the Hospital Design Process

Hospital Concept Design

planning design and construction of healthcare facilities

  • Translating your vision into reality The Concept Design is the first step by our Architect to translate your vision into reality. This is based on how well the Architect interprets your brief creatively and engage with you until it is fully understood. At this stage we also carry out extensive research, site visits and have regular conversations with you as the Client and various User Groups.
  • Feasibility Study need Prior to the Hospital Planning and Architecture Design process ideally there should be a Feasibility Study carried out, the objective of which is to understand the healthcare requirements in the target area of the Hospital. This helps us to finalise the services and even the specialities and get a fair idea of the expected patient load too. The Hospital Concept Design should comprehensively address all these requirements.
  • Conceptualisation In the Concept Design we will provide the elevation of the Hospital Building, block relationships of the departments showing area, shape and location within the building and of the vertical circulation elements such as elevators and staircases and the layout of the horizontal circulation routes (corridors)
  • Ensuring functionality and statutory /regulatory compliance While Designing Hospitals we also ensure the efficient functionality of the Hospital within the built-up area & local laws and planning guidelines as needed to ensure full compliance with the National and / or International Hospital Quality Accreditations like the NABH & JCI.

Once Concept is approved, the detailed Architecture is done giving the complete design of the Hospital, including the Civil Components, Structural Design, Electrical & Mechanical Services.

Detailed Hospital Architecture Services  covering

  • Complete design of the Hospital / Civil component
  • Preparation of the Master Plan for the whole complex
  • Designing for the hospital building
  • Interior Designing - Façade, Furniture, 2D & 3D Views, Material Chart
  • Internal space and facility planning
  • Ancillary support services
  • Building blocks design
  • Layout of rooms within each department for the hospital
  • Schematic drawings giving plans, elevations and sections of the proposed building
  • Space Programming
  • Bill of Quantities (BOQs)
  • Design Vetting for New Hospitals and Nursing Homes as per the mandatory NABH / NBC / Fire / National and International Clinical Guidelines - Compliances / Local Bylaws

Hospital Structural Design Services  covering

Hospital Upgrade Renovation Projects

  • Complete design of the structural framework
  • Appropriate framing system
  • Detailed construction drawings for the work on site

Design of Services (MEP)  covering

  • Electrification design including HT, LT & Gensets, Heating, Ventilation & Air Conditioning (HVAC) design
  • Water Supply
  • Fire fighting and Protection System Design
  • Elevators specification
  • Telecommunication System
  • Public Address Systems / CCTV surveillance
  • Medical Gas Pipe line (MGPS) Design
  • Data and Voice Networking
  • Building Management Systems
  • Sewage treatment plant and disposal systems
  • Rain water harvesting for the complex

Critical Areas Designs  covering

  • OT & CSSD Complex
  • Accident & Trauma
  • Radiology & Radiotherapy
  • Nuclear Medicine designs

Other Designs  covering

  • Exteriors – Landscaping Design
  • Laundry and Kitchen Layout & Design

Our Clients

Some of our Latest Hospital Architecture Planning, Full and Internal Design, Layout Design, OT Renovation, Structural Engineering Design, Interiors Design, Hospital Renovation, Healthcare MEP (Mechanical, Electrical, and Plumbing), and Medical Equipment Planning Projects:

  • Technical Consultancy Services to CIEL, St.Lucia, West Indies, Eastern Caribbean
  • RAAG Healthcare, Indonesia - Integrated Health City (Concept & Project Report)
  • Planned Hospital at Trinidad & Tobago, Caribbean, South America (Architecture Design)
  • Sri Mariamman Ltd Queensland, Australia
  • Takdhum Limited, Dhaka, Bangladesh
  • Meridian Hospital, 300 Beds, Chennai (All Services)
  • ZOHO Hospital, 200 Beds, Chennai (All Services)
  • Madras Medical Mission (MMM), 300 Beds, Chennai (OT Renovation - 8 Nos.)
  • Frontier Lifeline Hospital, 100 Beds, Chennai (Renovation. Design, Interiors)
  • Equitas Bank Hospital, CSR with TATA Memorial, 100 Beds, Chennai (Equipment Planning)
  • ANBU Hospital, 100 Beds, Dharmapuri (All Services)
  • Padmabati Devi Hospital, 1000 Beds, Jamshedpur (All Services)
  • Sugam Hospital, 100 Beds, Chennai (Renovation, Layout Design, Interiors)
  • Dr Prasad's Ortho Hospital, 40 Beds, Khammam, Telangana (All Services)
  • JPRAS Hospital, 40 Beds, Hyderabad, Telangana (Internal Layout, Design & NABH Accreditation)
  • Punya Hospital, New Block 45 Beds, Bangalore, Karnataka (Internal Layout, Design & NABH)
  • Dr Anup Hanchinal - New Hospital, Mahalingpur, Belagavi, Karnataka (Planning & Design)
  • Anup Hospital, 50 Beds, Bagalkot, Karnataka (Detailed Design Services)
  • CRK Diagnostics, Hajipur, Bihar (Feasibility, Project Report & Design)
  • Asirvatham Hospital, New Block - 50 Beds, Madurai (Planning & Design)
  • Dr Sadiq Basha Hospitals, New Hospital, 35 Beds, Chengalpet (All Services)
  • Dr Hariharan - New hospital, Sithalapakkam, Chennai (Internal Planning)
  • Dr Gopinath Hospital, Coimbatore (Internal Planning)
  • Aftab Hospital, Giridih, Jharkhand (All Services)
  • Liven Hospital in Jangareddygudem, Andhra Pradesh (Internal Design)
  • Shanmuga Hospital Private Limited, Salem, Tamil Nadu
  • Pinaki Medicare Private Limited, Kota, Rajasthan
  • Lucesco LLP, Bhayander, Maharashtra
  • Planning and Architecture Design for MSH, Pozhichallur, Chennai
  • Hibeams Scans in Royapuram, Chennai
  • Fenix Speciality Hospital, Tirur, Kerala
  • Shri Chaitanya Mahaprabhu Hospital Pvt. Ltd. Sagar, Madhya Pradesh
  • Sai Hospital, Holalu, Karnataka
  • Planned Hospital in Tirunindravur, Chennai (All Services)
  • Kumud Mohabey (Dr.) Memorial Hospital (Concept and Detailed Design) Rajnandgaon, Chhattisgarh
  • Basant Sahney Hospitals, Hyderabad, Telangana (Review of existing Infrastructure, Facilities, Equipment, Licenses and Approvals, Staff, and other Resources)
  • Stavya Lifecare Trivandrum, Kerala (Drawing vetting with NABH Compliance)
  • Aria Multispeciality Clinic, Bengaluru, Karnataka (Internal Planning & Design of Clinic)
  • Planned Hospital in Pammal, Chennai (Project Report, Architectural Design)
  • Asirvatham Hospital, Madurai
  • Divine Hospital, Ranchi, Jharkhand
  • Gomathi Hospital, Kallidaikurichi (Internal Planning, MEP Design & Layout)
  • Healing Hands Hospitals, Pune
  • Katihar Medical College, Bihar - 600 Beds (Design of OT Complex, with 12 OTs)
  • PBS Urology, Varanasi
  • Shetty Eye Hospital, Karwar, Uttara Kannada
  • Sri Krishna Nursing Home, Tenali, Andhra Pradesh
  • Umri Christian Hospital, Yavatmal, Maharashtra
  • Vaishnavi SS Hospital, Bhopal, Madhya Pradesh
  • YRG Care, Chennai - Hospital and Laboratory (Renovation and Upgradation)
  • Azidus Hospital, Nolambur, Chennai
  • SSK Global Diabetes Centre, Nellore
  • Vijay Kumar R (Dr.) (Rathinaam Educational Group) Aruppukottai
  • Golapalli Pavan (Dr.)'s Hospital, OMR, Chennai
  • Parvathee Hospital Chennai
  • Chandrasekar Healthcare & Research Pvt. Ltd.(Dr.G.Pawan Kumar) Chennai
  • Meera Maternity Kumbakonam

Some of our Hospital Facility Design Works

Healthcare Inpatient Room Design

Useful Articles related to Hospital Design

Impact of Colors in Hospital Design

Date of the Study: Dharmapuri, 2020 October

While there is no question about the importance of Hospital Design in the Patient have a much better healing experience, the role Colours in Design has not been as understood and accepted. Color has always had a huge effect on the mood of a person. Researchers have explored this aspect and discovered that use of certain colors have an affect on physiological aspects like heart rate, blood pressure, and respiration, making it imperative to use it when designing especially Hospitals. Read More...

Hospital Interior Design Rules

When we design the interiors of Hospitals, we are just not choosing nice paintings and pretty furniture. Along with being aesthetically pleasing, the we ensure the Hospital has a functional environment. Right from the entrance to the Hospital color, lighting and signage is used in the right way to convey a warm and inviting atmosphere. Read More...

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Project 2 Hospital Name : Sugam Hospitals Total Beds : 100 Location : Chrompet & Tiruvotriyur, Chennai, Tamil Nadu Scope of Work : Interior & Exterior Renovation, Market Feasibility Analysis Project Photo Gallery :

project hospital planning

Project 3 Hospital Name : ArcelorMittal Nippon Steel India Total Beds : 250 Location : Paradeep, Odisha Scope of Work : Hospital Project Report, Hospital Concept Planning Project Photo Gallery :

project hospital planning

Project 4 Hospital Name : Padmabati Hospital Total Beds : 1000 Location : Jamshedpur, Uttar Pradesh Scope of Work : MFS, Project Report, Architecture Design and Planning, Equipment Planning Project Photo Gallery :

project hospital planning

Project 5 Hospital Name : Gowsbai Hospital Total Beds : 30 Location : Chennai, India Scope of Work : Feasbility Study, Hospital Project Report, Design & Planning, Medical Equipment Planning, NABH Accreditation Project Photo Gallery :

project hospital planning

Project 6 Hospital Name : Sugah (Zoho) Hospital Total Beds : 200 Location : Chennai, India Scope of Work : Market Feasibility Analysis, 200 Bed Hospital Project Report, Internal Planning, Hospital Equipment Planning, NABH Support Project Photo Gallery :

project hospital planning

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Guidelines for Design and Construction of Healthcare Facilities

Building Healthcare Facilities for the Future, that are Patient Friendly, Safe for the Patients, Visitors and Hospital Staff, Energy Efficient and Environment Friendly.

Hospital Infrastructure Planning and Design

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project hospital planning

Fears for waiting lists as Calvary Health pulls out of Launceston General Hospital co-location plan

Sue Kole in her backyard hugging her dog

After surviving a stage three breast cancer diagnosis, Wynyard resident Sue Kole thought she had a plan to get her life back on track.

Confronted with the legacy of a double mastectomy, two rounds of chemotherapy, seven weeks of radiation therapy and a further year of additional therapy due to side effects, Ms Kole was finally eligible for reconstructive breast surgery when her treatment ended in 2018.

More than five years later, the 53-year-old is still sitting on a public waiting list to have the procedure at the Launceston General Hospital (LGH) — an almost two-hour drive from home.

Sue Kole sits at a dining table with a printed letter from the Tasmania Health Service in front of her

"'I've got such poor body image … I can't go to the beach swimming," Ms Kole said.

"I know people stare at me because not only am I flat-chested, but I've been quite disfigured by the surgery as well.

"I can't look in a mirror, I just feel that repulsed by my body."

Ms Kole is now worried she will have to wait even longer for the surgery after plans for a new co-located private hospital in Launceston were thrown into doubt.

Falling at the final hurdle

Seven years ago, private health provider Calvary Health Care placed an unsolicited bid to build a co-located private hospital at the LGH.

But it has now pulled the pin just months before construction was due to start, citing "insurmountable" budget pressures.

According to the project development agreement signed between the state government and Calvary in 2022, the $130 million hospital would have seen the creation of 168 new beds, 10 operating theatres, two procedure rooms and specialist oncology facilities.

Under the agreement, a two-year trial of 24/7 private patient admissions was promised, with the aim of "freeing up capacity", allowing for patients to move between the LGH and the new private hospital.

Drone shot of Launceston General Hospital.

Calvary had also planned to close its existing smaller hospitals in Launceston, St Luke's and St Vincent's.

The plan represented a key plank in the government's attempt to reduce the elective surgery waitlist and wait times at the LGH.

Recent data showed 3,350 people were waiting for elective surgery at the LGH, the longest waiting list out of all four of the state's major hospitals.

Those seeking elective surgery at the LGH waited an average of 219 days beyond the clinically recommended time for elective surgery.

'Our patients are going to suffer'

The future of St Luke's and St Vincent's hospitals is now under a cloud, with Calvary informing the Australian Nursing and Midwifery Federation that operations at its two Launceston-based hospitals were under review.

The review has sparked significant concern for the federation's Tasmanian secretary, Emily Shepherd.

"Our view is that there would need to be a continuation of services at both sites, whether they were operated by Calvary Health Care Tasmania or another health care provider," she said.

"The loss of those beds and services in Northern Tasmania is something that would be extremely concerning."

Emily Shepherd looks at the camera.

John Saul from the Australian Medical Association said it would be harder to "provide a good quality service" for people living in the state's north.

"We know knees and hips, for example, replacements, over three-quarters of them are usually done in the private system," he said.

"And sadly, this will be lost to the Launceston people."

Dr Saul believes without a private hospital, the LGH will face increased challenges in recruiting skilled doctors who are keen to work across both the public and private systems.

He is concerned the decision will contribute to "increased delays and reduced service levels" as potential new doctors are put off by the uncertainty.

"We're going to have less staff, less doctors. So we're not going to be able to deliver as many services to the people of northern Tasmania.

"Sadly, our patients are going to suffer as a result of this."

In a statement, Calvary Health Care's national chief executive officer Martin Bowles said that Calvary was "committed to remaining part of the region".

"Calvary can assure the northern Tasmanian community that it is business as usual for St Luke's and St Vincent's Hospitals in Launceston while we investigate options to enhance our services."

Before the state election was called , Health Minister Guy Barnett said the Rockliff Liberal government was committed to the private hospital as part of its planned $580 million overhaul of the LGH.

"Our long-term plan … is a co-located hospital here in Launceston next to the LGH," he said.

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Pair of Prince Albert projects show promise for city, but prices have risen

Some people wary of increased costs for hospital, new facility.

project hospital planning

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The amount the province expects to pay for a hospital expansion in Prince Albert, Sask. — one of two major ongoing projects in the city — seems to have almost tripled in just under four years.

When the Victoria Hospital expansion project was announced in March 2020, the province committed to provide "more than $300 million."  On Feb. 1 of this year, the provincial government announced it has contracted PCL Construction Management Inc. to manage the expansion for $898 million.

The costs include design and construction of a new acute care tower with a heliport pad, an expanded emergency department, larger operating rooms, pediatrics, maternity, NICU and new medical imaging, and 69 more beds (up to 242 from 173), according to a government news release. 

"It brings us a hospital that we don't have to go to Saskatoon, for the north. You know, [the] north now, they fly into Saskatoon," Prince Albert Mayor Greg Dionne told CBC.

It's the most government or private money put toward a project in the history of Prince Albert, according to SaskBuilds and Procurement Minister Joe Hargrave.

  • Sask. government commits more than $300M to expansion of Prince Albert's Victoria Hospital
  • Government of Saskatchewan adds 6 new ICU beds across 3 hospitals

Sara Nichols — the assistant deputy minister for infrastructure, design and delivery at the Ministry of SaskBuilds and Procurement — said it's typical for the cost of a project to change from its early stages and blamed rising construction costs for driving up the price. 

She said hospital construction is the most complex type the ministry manages and that cost changes can be more pronounced on facilities with specialized equipment.

project hospital planning

Nichols said the cost for non-residential construction in Saskatchewan has increased by more than 41 per cent since 2017, and concrete and steel costs have increased by 30 per cent and more than 80 per cent, respectively, since 2020. 

"When we actually have bids coming in, the final price is really not final until we sign an agreement, and so the costs are monitored very closely and we work very closely with the design builder over time on their financial submission," she said in an interview with CBC.

"We've also just been in this time period where there have been significant cost escalations."

a digital rendering of the exterior of the Prince Albert Victoria Hospital.

Nichols pointed to projects in British Columbia with cost increases as examples: the Surrey Hospital and Cancer Centre priced at $1.66 billion in 2021, then $2.88 billion in 2023, and the Dawson Creek Hospital at $378 million in September 2020, then $590 million in June 2023.

Nichols said a more specific cost layout for the next several years will come out in the next budget.

Gage Haubrich, the Prairie director at the Canadian Taxpayers Federation, said the government needs to be clear about how it is spending taxpayer dollars and explain why there was a jump in price.

"Inflation is obviously part of it, [but] we all know that inflation wasn't 300 per cent," he said. 

He said that, from what he's seen, the costs of government projects balloon and estimates are consistently off.

The Prince Albert hospital project is expected to begin construction in the spring and be completed in 2028.

$18M loan approved for aquatic, rink facility

In a divisive vote (6-3), Prince Albert city council approved an $18-million short-term loan for its Aquatic and Arenas Recreation Centre project southeast of the city.

When the project is finished, it is expected to have a pair of NHL-sized ice rinks and a 51,500-square-foot aquatic facility with a nine-lane competitive swimming pool, wave pool, lazy river and waterslides.

During a council meeting on Monday, one councillor called for a hold on the project, calling it financially irresponsible to go forward with another loan. Another shot back that it's financially irresponsible to halt the project in the year it's expected to open.

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The project began before the COVID-19 pandemic, with a $60-million bill to be divided between the federal government ($24 million), the provincial government ($20 million) and the city ($16 million from a loan).

A June 2022 city council report shows that price changed, citing inflation. Administration was ordered to get another $30-million loan. Now, after the recent additional $18-million loan, the project is budgeted at $118 million and is nearly finished construction, according to the city.

"We were like everybody else. We got caught in the upswing in the market," Dionne said, referencing rising costs and inflation.

Planning for millions from donors

The $18-million loan is meant to fill a hole in the funding model that Dionne is confident donors will replenish. To do that, the city has hired a third-party company for $648,900, with the goal of raising $20 million.

He said failing to find donors earlier to raise the $18 million was an oversight.

"When you have a project this big, you [overlook] some things," he said.

He said bigger donors prefer making structured payments over a length of time, similar to the five years the city has to pay off the loan.

pylons encircle a large building under construction

Prince Albert Ward 3 Coun. Tony Head said he is concerned about those donations not coming in and how deep in debt the city will be afterwards.

The city recently extended its debt limit from $75 million to $120 million, and is nearing that ceiling again. Dionne said the city could vote to move that ceiling higher if needed.

"I didn't see anything in the report about the exact number or who's committed. I'm not comfortable making important decisions without having accurate information in front of me," Head said.

"My experience is whenever money is needed for this project, it gets approved no matter what. Our bus services for our seniors and disabled residents are struggling, we have no money for that. Our homeless population struggle, but there's no money for that."

The aquatic centre is expected to be complete by the end of 2024.

ABOUT THE AUTHOR

project hospital planning

Dayne Patterson is a reporter for CBC News in Saskatchewan and is based in Saskatoon. He has a master's degree in journalism with an interest in data reporting and Indigenous affairs. Reach him at [email protected].

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  • Study Protocol
  • Open access
  • Published: 19 February 2024

Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial

  • Maria Romøren 1 , 2 ,
  • Karin Berg Hermansen 3 ,
  • Trygve Johannes Lereim Sævareid 1 ,
  • Linn Brøderud 1 ,
  • Siri Færden Westbye 1 ,
  • Astrid Klopstad Wahl 4 ,
  • Lisbeth Thoresen 4 ,
  • Siri Rostoft 5 , 6 ,
  • Reidun Førde 1 ,
  • Marc Ahmed 5 ,
  • Eline Aas 7 , 8 ,
  • May Helen Midtbust 3 &
  • Reidar Pedersen 1  

BMC Health Services Research volume  24 , Article number:  220 ( 2024 ) Cite this article

Metrics details

Acutely ill and frail older adults and their next of kin are often poorly involved in treatment and care decisions. This may lead to either over- or undertreatment and unnecessary burdens. The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions.

This is a cluster randomized trial with 12 hospital units. The intervention arm receives implementation support for 18 months; control units receive the same support afterwards. The ACP intervention consists of 1. Clinical intervention: ACP; 2. Implementation interventions: Implementation team, ACP coordinator, network meetings, training and supervision for health care personnel, documentation tools and other resources, and fidelity measurements with tailored feedback; 3. Implementation strategies: leadership commitment, whole ward approach and responsive evaluation. Fidelity will be measured three times in the intervention arm and twice in the control arm. Here, the primary outcome is the difference in fidelity changes between the arms. We will also include 420 geriatric patients with one close relative and an attending clinician in a triadic sub-study. Here, the primary outcomes are quality of communication and decision-making when approaching the end of life as perceived by patients and next of kin, and congruence between the patient’s preferences for information and involvement and the clinician’s perceptions of the same. For patients we will also collect clinical data and health register data. Additionally, all clinical staff in both arms will be invited to answer a questionnaire before and during the implementation period. To explore barriers and facilitators and further explore the significance of ACP, qualitative interviews will be performed in the intervention units with patients, next of kin, health care personnel and implementation teams, and with other stakeholders up to national level. Lastly, we will evaluate resource utilization, costs and health outcomes in a cost-effectiveness analysis.

The project may contribute to improved implementation of ACP as well as valuable knowledge and methodological developments in the scientific fields of ACP, health service research and implementation science.

Trial registration

ClinicalTrials.gov Identifier NCT05681585. Registered 03.01.23.

Peer Review reports

The world’s population is rapidly ageing, requiring health systems to adapt to this population shift. Older adults represent a large proportion of hospitalized patients [ 1 ], they often have comorbid chronic illnesses and disability, and acute illness often comes with deterioration of physical health and cognitive function [ 2 ]. Overall health care and hospital utilization increase dramatically in the last months of life and a large proportion of old adults die in hospital [ 3 , 4 , 5 ].

It is well known that frail older adults and their relatives are often poorly involved in treatment and care decisions [ 6 , 7 ]. At the same time, the communication between the service levels during admission and discharge is often deficient [ 8 , 9 ]. This may lead to both over- and under treatment [ 7 , 10 ] and considerable and unnecessary risks, burdens, distrust, conflicts as well as costs, for example because of undue hospitalization [ 10 , 11 , 12 , 13 ]. Advance care planning (ACP) is a well-documented tool to comply with the ethical and legal imperative to involve the patient and their relatives in the planning of current and preparing for future treatment and care [ 14 ]. ACP has its origins in the principle of respect for the patient’s autonomy and the right to self-determination [ 15 ]. It can be defined as the process of exploring the patient’s values and preferences for care and treatment at the end of life before decisions must be made [ 16 ]. ACP can improve quality of communication, prevent decisional conflict [ 17 ], improve health and satisfaction for patients and their relatives, and increase staff competence and confidence [ 11 , 12 , 18 , 19 ].

Despite the evidence of the benefits of ACP and despite being key priority in national and international policies [ 16 , 20 , 21 , 22 ], implementation is patchy [ 23 ], and ACP remains underused in the health care services [ 6 ]. A common strategy to facilitate the adoption of new practices is to develop guidelines [ 20 ]. Internationally, ACP guidelines exist [ 16 , 20 ] but the gap between policies and practice remains large [ 6 , 15 ]. Trials that include both implementation and intervention strategies to improve ACP in ordinary health care services can contribute to strengthen the pathway from guidelines to practice [ 24 ]. ACP is a complex intervention [ 25 , 26 , 27 ], and the full range of barriers and facilitators to implementing ACP have not been studied. Examples of barriers include reluctance and feeling of insecurity to talk about existential issues and the limits of medicine, poor communication skills, paternalism, specialisation, and fragmentation [ 7 , 28 ]. There are also more general barriers to translating evidence into everyday clinical practice, such as lack of time [ 29 ] and commitment by leadership. Elements supporting successful ACP implementation [ 30 ] include whole-system approach, targeting multiple stakeholders concurrently (patients, caregivers, health care personnel), improved communication, application of guidelines, and skills training.

The Norwegian health and care services do well in international comparisons of quality of treatment, and Norway is also better equipped to meet the challenges of an ageing population than most other countries [ 31 ]. Important reasons for this are the Nordic welfare model and a strong economy. Although the health care services have become more patient-centered in recent years, ACP is, as in other countries, rarely implemented. ACP is to a certain extent in use in Norwegian nursing homes and in the palliative care setting, more seldom in other specialist and hospital care or primary health care. Advanced directive forms are little used, and neither advanced directives nor ACP are explicitly regulated by health legislation [ 32 ]. In general, we still lack evidence to answer the questions of timing, place and who should do ACP, to implement ACP on a large scale in routine services. There is evidence indicating that initiating ACP in nursing homes may be too late for the patient to be able to participate themselves [ 33 , 34 , 35 ]. For this study, we considered that it would be too challenging at the time being to implement ACP in primary health care outside nursing homes, and that available evidence was not sufficient for our study design. Through discussions with key stakeholders and based upon available evidence and knowledge of Norwegian health care services, we decided to focus on frail older home dwelling adults acutely admitted to hospital.

In this context, our project will—through the use of mixed methods and responsive evaluation—develop, put into practice and evaluate interventions to implement ACP in Norwegian geriatric units and medical wards with geriatric beds. We use a cluster randomized design to measure and compare changes and differences in implementation levels, health service outcomes and clinical outcomes for patients and next of kin between intervention- and control sites. Within this trial design, we employ formative evaluation to evaluate and improve the implementation processes, and we will use qualitative studies to investigate and explore the implementation process and the significance of ACP for central stakeholders in the participating geriatric units. We will also qualitatively explore key barriers and facilitators for ACP among stakeholders in a broader context, including other health care services and at the municipal, regional, and national level. A novel and comprehensive fidelity scale will be developed by the project group and used in the trial to assess the implementation level, penetration rate and the content and quality of the ACP in the intervention and control arm, and to guide the implementation strategy in the intervention arm. It will after the project be made available as a tool for coming research and quality improvement in the field.

The overall aim of the project is to improve health services, user involvement and patient-centered care for frail older adults and their next of kin, in an efficient, sustainable, and coordinated way, through better implementation of ACP.

Primary objective

To evaluate whether the implementation support, relative to no support, is associated with improved implementation of ACP and with better involvement of patients and next of kin in geriatric units.

Secondary objectives

To measure the present level of implementation of ACP in all participating hospital units.

To evaluate whether the implementation support, relative to no support, is associated with improved implementation of ACP, measured with the ACP fidelity scale (sum score, the quality subscale, the implementation subscale and the penetration rate subscale).

To identify barriers to, facilitators for and experiences with implementing ACP among the stakeholders at the a) clinical, b) health care service- and c) municipal, regional and national level.

To explore moral dilemmas and conflicting interests related to ACP, and strategies on how to resolve them.

To explore benefits and disadvantages with ACP among patients and their next of kin, and to explore the benefits and disadvantages of both the implementation support and ACP among health care personnel and the implementation teams.

To investigate whether the implementation support is associated with improved quality of communication and decision-making when approaching the end of life for patients and next of kin, better congruence between the patient’s preferences for information and involvement and the attending clinician’s perceptions of the same, and improvements of other relevant outcomes for patients, next of kin and the attending clinician.

To assess whether higher level of implementation (fidelity) of ACP is associated with improved outcomes for patients, next of kin, the staff and the services.

To measure, before and during the implementation process, health care personnel’s perceptions, attitudes, self-efficacy, confidence in, and experiences in relation to information giving and involvement of patients and next of kin.

To measure healthcare utilization, costs, and the cost-effectiveness of the implementation and of ACP in the routine health care in hospital units.

Trial design

The project is a multicentre cluster randomized controlled trial (CRCT). Each participating geriatric unit, with responsibility to provide medical care to acutely admitted older medical patients, constitutes one cluster and is the unit of randomization. Figure  1 gives an overview of the study design. The article conforms to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) [ 36 ] (Additional file 1 ), and the study results will reported in accordance with the Consort 2010 extension to cluster randomized trials. All methods carried out in the study will be performed in accordance with relevant guidelines and regulations.

figure 1

The study design of the Norwegian ACP trial

Implementation of ACP in the routine health care in Norwegian hospitals is pioneering work, so the geriatric milieu was chosen because of their preexisting focus on and competence in communication, patient involvement and interdisciplinarity in the care for acutely admitted frail older adults. All 14 hospitals in the South-Eastern Norway Regional Health Authority with a geriatric unit or medical wards with geriatric beds were invited to participate in the trial. Of the 14 hospitals, 12 agreed to participate in the trial. All units treat patients from their discrete geographical catchment area, with a total catchment area of 2 372 150 inhabitants, 43% of the total population in Norway. The reason given for non-participation was the lack of capacity to engage in a research project. A full list of the participating units, situated in both urban and more rural areas, is available at ClinicalTrials.com. The difference in size is partly due to differences in the size of the catchment area, and it also reflects the differences within the Regional Health Authority in how geriatric medical services are organized and prioritized.

Selection, allocation of clusters and sample size

The organization and size of the acute geriatric inpatient care in the included hospitals varied a lot. We selected the units that a) had geriatric doctors and b) were either defined geriatric units, or medical wards with geriatric beds. One exception is one hospital that has a general medicine unit without defined geriatric beds, but with a geriatric doctor and with similar responsibility towards the geriatric patients in their catchment area as the other units. In Norway, many geriatric patients are admitted to various medical wards (cardiology, respiratory medicine, nephrology etc.). The geriatric units and geriatric beds are usually reserved for acutely ill home-dwelling older patients who are expected to benefit from a multidisciplinary geriatric team approach: to evaluate their functional and cognitive status as well as their level of frailty and to develop an individualized plan to preserve function along with treating the acute condition. Three of the units also included beds for stroke patients, and one of the units only had beds defined as "stroke beds". The units with stroke beds were included as a whole if the unit had the main responsibility for geriatric patients in need of acute hospital admittance in their catchment area and were the unit with the highest level of geriatric expertise at the hospital (at least one geriatrician among the staff). The beds in these units were often used interchangeably for geriatric patients and stroke patients depending on the needs.

The units were sorted from one to 12 according to the number of geriatric beds and then stratified into three strata: four clusters with 16 to 23 beds, six clusters with 6 to 10 beds and two clusters with 4 and 5 beds respectively. In each block, the clusters were randomized to either the intervention or the control arm with an allocation ratio of 1:1. An independent professor in epidemiology performed the allocation using the Microsoft Excel RAND-function, only knowing the numbers of the clusters. The randomization was performed to achieve a balance in unit types in the intervention and control arm and a similar size of the two arms including a similar number of admitted patients filling the inclusion criteria. All hospitals are located in cities or towns. The purpose of the stratification was primarily to achieve a balance in the number of patients and next of kin between the two arms, and secondly to include units of various sizes in both.

The study has primary outcomes for the implementation and for the clinical effectiveness. The primary outcome for the implementation outcome sub-study is the differences in fidelity changes between the arms. The unit of analysis for the fidelity scores is the health care units or clusters. Fidelity is rated on 5-point scales (1 = poor fidelity, 5 = high fidelity). Based on previous research (mean difference 1.82 and average SD 0.80 after 18 months with implementation support), we have calculated that we need at least four clusters in each arm to show that implementation support gives a significant increase in fidelity, based on 5% two-tailed significance and 80% power. If the differences are smaller in our study, we will need a larger sample. Due to the possibility of unit drop-out during the project period and to secure sufficient power, we have included six units in the intervention arm and six in the control arm.

The primary outcomes for the clinical effectiveness study “The triadic sub-study with patients, next of kin and clinicians” are described under “outcomes”. The unit of analysis is the individuals recruited in each cluster. Since we have not found comparable studies that have published data on these instruments, we decided to use a 0.5 SD improvement (medium effect) when calculating the sample size. Based on a 0.5 SD increase in the primary outcome and an Intra-class Correlation Coefficient (ICC) of 0.05, we need 132 patients in each arm or 22 per cluster with six clusters in each arm to achieve 80% power to detect a difference in the primary outcome among patients, between groups with a certainty of 95%. Taking into account the possibility of patients in the control arm receiving ACP, and incomplete or missing data, we aim to recruit at least 35 patients per cluster. A similar power calculation with the same conservative assumptions has been done for the primary outcomes for next of kin and clinicians with the same results (35 next of kin and 35 clinicians per cluster).

Research methodology

The multicentre trial is both an implementation study and a clinical effectiveness study. Our project includes two complex interventions on a large scale in ordinary services: a clinical intervention (ACP) and an implementation intervention. We will use a responsive evaluation approach [ 37 ] in combination with participatory action research, the CRCT design, health economics and empirical ethics. Responsive evaluation is characterised by engagement with all stakeholders, and combining professional, scientific, and experiential knowledge. Furthermore, we want to do multilevel evaluation research also outside the units participating in the CRCT and use process evaluation to provide feedback on the preliminary results to the intervention arm as part of the implementation intervention (formative evaluation). In sum, this requires the use of mixed methods (i.e. quantitative and qualitative research methods) – multidisciplinary approaches, and to include different stakeholders and sub-studies with different primary outcomes.

The project design emphasises strong stakeholder involvement before, during and after the project. The health care personnel, the patients, the next of kin, and the health services will play an important role in the development of effective implementation strategies and optimization of the ACP intervention: as stakeholders, as experts by experience, and through the data collected in the qualitative and quantitative sub-studies. The project plans and results will also be discussed at the annual network meetings of the national ACP network to get input and to inspire other research and innovation.

Our methodological design follows the Medical Research Council’s recommendations on evaluating complex interventions [ 26 ] and Proctor et al.’s recommendations on outcomes for implementation research [ 38 ]. That is, we include more than one method, both process and outcome research, and formative evaluation, more than one primary outcome and different types of outcomes. This approach makes it possible to monitor and adjust the implementation process and study the effect of ACP-implementation both on the individual and organisational level. In the current project, we will further exploit and develop this fidelity scale to assess the implementation of ACP thoroughly, and to be able to assess and compare the levels of ACP implementation, service outcomes, and outcomes for patients and next of kin.

Piloting and feasibility of questionnaires and interview guides

Two past large multi-center studies from Centre for medical ethics (CME), “Implementing advance care planning in nursing homes” and “Implementation of guidelines on family involvement for persons with psychotic disorders in community mental health centres (IFIP)-trial” have ensured knowledge and experience with feasibility, implementation and evaluation, and serve as pilots for the current trial [ 39 , 40 ]. All interview guides and questionnaires are built upon these and other relevant past studies [ 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ], and have thus been pretested in implementation, health service, and clinical research focusing on involvement of severely ill patients and their close relatives in different health care contexts. Further tailoring, piloting and testing will be performed among older patients, next of kin and health care personnel in geriatric units, and the questionnaires will be adjusted according to feedback on relevance and feasibility.

The ACP interventions

The ACP interventions in this study, combining implementation strategies, an implementation intervention and the clinical intervention ACP, were developed by the project group. It is building upon research at CME on end-of-life ethics, patient involvement, decision making processes for older patients and their next of kin and ACP in nursing homes in Norway, and national and international research and guidelines on ACP and end-of-life decision-making.

The ACP interventions consist of the following elements (described in detail in Additional file 2 ).

I Clinical intervention: advance care planning

1.1 Routine identification, information and invitation to ACP to all eligible patients and next of kin.

1.2 ACP conversations routinely provided to all consenting patients and their next of kin.

1.3 Documentation and collaboration with other health care services and levels.

II Implementation intervention

2.1 Implementation team.

2.2 ACP coordinator.

2.3 Training and supervision: Kick-off, training of resource persons and health care personnel including practical exercises, monthly contact with units, network meetings.

2.4 Toolkit and shared resources: ACP guideline, pocket card, teaching material, information leaflets, documentation templates etc.

2.5 Structured fidelity measurements of the implementation level of a) the implementation interventions and b) the clinical intervention, with tailored feedback and supervision.

2.6 Evaluation of the intervention and implementation.

III Implementation strategies

3.1 Ensuring leadership commitment.

3.2 Responsive evaluation.

3.3 Whole ward approach.

3.4 Train the trainer model.

3.5 Sustainability after the project.

The implementation strategies

The hospital units in the intervention arm will receive support through the implementation strategies and implementation interventions for 18 months to be able to use the clinical intervention ACP in routine health care. The control units will provide treatment as usual during this period and receive implementation support after the last fidelity measurement at 18 months.

To secure sustainability, both the evaluation plan and the implementation support emphasise a “whole ward approach” [ 39 ]. By this we mean recruiting whole units through the CRCT design (and not only individual patients or next of kin), involvement of all employees, leadership commitment, ACP performed by regular staff, train-the-trainer model, minimal off-site training, freely available ACP-guideline and didactic materials, ACP-invitations to all patients in the units who are able to participate, encouraging next of kins’ participation, and supported decision-making if the patient is cognitively impaired [ 50 ]. We have recently used parts of this approach in an ACP-study in nursing homes [ 39 , 51 ]. Our results demonstrate significant improvement of user and family involvement on entire units, not only for patients offered ACP [ 52 ].

The implementation support starts with a kick-off for all units. An initial meeting with all involved parties at each unit is recommended. All participating units will recruit a local coordinator for the project. Furthermore, the intervention units assign an implementation team, consisting of one or more health care professionals and the unit leader, which will ensure the local implementation. The project group will provide, in a train-the-trainer model, training and supervision for these local resource persons. We will encourage the implementation teams to meet 1–2 times monthly in the intervention period, and the project group will have monthly joint meetings with the teams digitally. The results from the detailed fidelity assessments (described below) will be used to provide tailored feedback to each intervention unit three times during the implementation period (formative evaluation). Additionally, during the 18 months of intervention, we will gather the implementation teams across all the intervention units in network meetings every sixth month for networking and discussion. Written notes from these meetings will be included in the qualitative evaluation study (see below).

Participants

From the units participating in the CRCT we have the following main categories of participants: Patients, next of kin, health care personnel and implementation teams, including health care professionals and unit leaders. These will be recruited from the units to take part in both the quantitative and qualitative studies. Furthermore, we will study barriers and facilitators qualitatively in a wider context, including stakeholders from other health care services, and from the municipal, regional, and national level. An overview of the respondents and sub-studies is presented in Table  1 , and each sub-study is described below.

Patients and next of kin

Patients and next of kin will be included by local health care personnel, led by the local research coordinator. In the quantitative triadic sub-study, patients and one close relative will be asked to participate together with the attending clinician in both the intervention and in the control arm (see below). In the qualitative sub-studies, patients and next of kin from the intervention units having experience with ACP will be invited to participate. Inclusion- and exclusion criteria for patients and next of kin in the triadic sub-study is described below. For the qualitative sub-study, we use similar criteria with some adaptations.

Inclusion criteria for patients

Home-dwelling

70 years or older

Acutely admitted to the participating unit

Sufficient language proficiency in Norwegian to respond to the questionnaire

Clinical frailty score of 4 or more

The physician responsible for the patient's medical care answers "no" to "Surprise question" from Gold Standards Framework proactive identification guidance

Both patient and a close relative (preferably the closest relative) would participate in ACP together if offered

Both patient and the close relative consent to participate in the research project

Exclusion criteria for patients

The patient is not competent to consent to research participation

The patient is expected to die within 24 h

The patient has participated in ACP prior to the current hospital admission

In the intervention arm

ACP is not conducted with patient, a close relative and physician before hospital discharge

The clinician that participated in the ACP conversation has not consented to research participation

In the control arm

The patient or the relative would not have been able to participate in ACP during hospitalization

An attending clinician has not consented to research participation

Inclusion criteria for next of kin

A close relative of a patient who fulfill all inclusion criteria and no exclusion criteria; and who would be willing to participate in ACP together with the patient if offered

18 years or older

Sufficient language proficiency in Norwegian to answer the questionnaire

Exclusion criteria for next of kin

The relative is not competent to consent to research participation

Health care professionals and local unit leaders

Health care personnel will have many roles in the implementation, the ACP intervention, and the research in this study. According to the whole-ward approach, the project encourages the units to include all clinicians in the ACP training, and some will actively participate in the clinical intervention, by providing ACP as a part of the clinical care. Dedicated clinicians will be appointed to roles as ACP-coordinators and implementation teams, thereby performing tasks related to both implementation and research. The implementation teams consist of clinical staff with a special interest or expertise relevant to ACP, and the closest leader. In Norwegian hospitals, the local unit leaders are in general health care professionals using some or all their time to lead the unit or a part of the unit. A research coordinator will be responsible for recruiting patients and next of kin to the quantitative and qualitative studies in collaboration with the staff.

The study will collect data from the health care personnel in four sub-studies: The fidelity assessments, a quantitative study to all health care personnel and the unit leaders, and the triadic study including an attending clinician, in both the intervention and the control arms, and qualitative interviews with ordinary clinicians and with the implementation teams in the intervention units.

In the triadic sub-study, the participating clinician will also provide clinical data about the included patient. This participating clinician should be closely involved in the health care provided to the patient during the hospitalization and have sufficient knowledge of the patient’s health and health care needs. If feasible, the participating clinician will be the attending clinician responsible for the patient’s medical care. In the intervention arm, the participating clinician should also be the clinician who participated in the ACP.

Stakeholders in a broader context

Two qualitative sub-studies include selected stakeholders to explore barriers and facilitators for ACP in a broader context. The first, already published, explores barriers and facilitators in a wider health care service context and includes health care professionals and chief physicians in hospitals and in municipalities [ 53 ]. The second explores barriers and facilitators at the municipal, regional and national level. In this study we include stakeholders who are relevant to health care policymaking: health politicians on a national level, national health authorities, high-level leaders in both the hospital and municipal health care system, professional associations, user- and interest organizations, as well as leaders of health care educations.

Due to the nature of the project, neither the units, the local leaders, the health care personnel nor the project’s researchers can be blinded to the hospital units’ allocation status. The project group is small, and the project’s researchers will contribute to all parts of the project, including developing the implementation program and providing the implementation support. This makes the researchers more familiar with and knowledgeable of all aspects of the units, which strengthens the tailoring of the intervention, and it improves the quality of the evaluation. On the other hand, having researchers evaluate the results of a program and the support they have provided themselves may lead to a risk of experimenter bias. This will be minimized by awareness of the risk of bias and by dividing the responsibility for the implementation and for the evaluation between different researchers. To prevent selection bias, patients and next of kin will not be informed about the hospital unit’s allocation status, but they may deduce this from the kind of treatment they receive. We assume that self-reported data and data collected from national registries to a low degree will be susceptible to bias.

Implementation outcome—fidelity

Fidelity is defined as the degree to which programs [in principle evidence-based practices] are implemented as intended. It is demonstrated that the fidelity with which an intervention is implemented affects how well it succeeds, e.g., impacts on the relationship between the intervention and its intended outcomes [ 54 ]. To our knowledge, only a few previous ACP-studies have assessed fidelity, but relating fidelity solely to the intervention or the degree to which an intervention is delivered as intended (i.e. the quality of ACP) [ 55 , 56 ]. This refers to a narrower conception of the term fidelity [ 54 ]. To capture both the complexity of ACP as an intervention and the complexity of the implementation process aiming to put ACP into routine practice, we developed a novel, broader and more comprehensive fidelity scale, including three subscales measuring:

The current level of implementation of the selected recommendations, i.e. adherence to the intervention (quality of ACP)

The penetration rate, defined as the percentage of consumers who are offered and receive ACP as an evidence-based practice, as measured against the total number of consumers who could benefit from the evidence-based practice [ 57 ]

The implementation process, by measuring the level and quality of selected implementation strategies and implementation interventions

We used Bond’s standardized methodology for developing and validating fidelity scales [ 58 ], and selected recommendations from national and international guidelines clustering them into key items [ 14 , 16 , 59 ]. The scale consists of 22 items that are scored from 1 to 5, where 1 equals poor implementation and 5 equals full implementation of ACP. The development and details of the scale will be published. The psychometric properties of the scale will be assessed, and we will optimize and ensure its usefulness and availability to other researchers and the health care services after the project period.

Data collection

We defined baseline as the situation before the start of the intervention, and the baseline fidelity measurements were conducted from May to August 2022. The participating hospital units were randomized to the intervention- or control arm after the baseline fidelity measurement in August 2022. The implementation period started with kick-off on Oct 25th, 2022, and will continue for approximately 18 months (when the inclusion for the triadic sub-study is completed, and before the last measurement of fidelity). Fidelity measurements in the intervention arm will be at baseline, at 7–10 months after the start of the intervention (May to August 2023) and at 18 months (April 2024). Fidelity measurements in the control arm will be at baseline and at 18 months. The second fidelity measurement is not done in the control group due to resource considerations, and to avoid influencing clinical activity in the control arm.

The fidelity scores at each unit will be based on a) interviews with leaders, b) interviews with resource persons, c) interviews with physicians, d) interviews with nurses, e) written material (e.g., information brochures or clinical procedures) and f) existing routine data (number of patients eligible for/offered/received ACP). Seven of the project members participate in the data collection, forming teams of two people visiting each site. Based on the interviews and available information, the two researchers will, at the end of the visit, score fidelity individually, and subsequently discuss possible discrepancies and decide on a consensus score.

Outcomes and data analysis

The fidelity measurements will provide an answer to the first primary outcome of this study, by comparing change in fidelity from baseline to 18 months in the intervention arm versus the control arm. We will report changes in total fidelity, in sub-scales and in relevant single items. The baseline fidelity scores provide data on the current level of implementation of ACP, thereby answering the first of the secondary objectives. Baseline data will be analyzed using descriptive statistics, including means, ranges, standard deviations (SD), and number of sites achieving low, adequate and full implementation of the various items. Interrater reliability will be investigated by calculating the ICC for total mean fidelity and for each item, using a one-way random effects analysis of variance model for agreement between two assessors. Difference between experimental and control arms in change on the ACP scale (primary outcome) from baseline to 18 months, will be assessed by an Independent samples t-test. The results will be presented as mean difference with corresponding 95% confidence interval (CI), p-value and effect size (Cohen’s d) with 95% CI. The differences between the experimental and control arms in change on the ACP scale and sub-scales will be assessed by linear mixed models with random intercepts for clusters. All analyses will be performed in SPSS, STATA or R.

Clinical effectiveness – The triadic sub-study with patients, next of kin and clinicians

In this sub-study, we will assess and compare ACP relevant outcomes between the intervention arm and control arm. As described, we use a triadic approach, by recruiting each patient together with a close relative, and an attending clinician. This allows us to assess and compare the perspectives of all three stakeholders across the two study-arms. We aim to include at least 420 triads in total from the two arms. Each person in each “triad” will complete a questionnaire inspired by past ACP-, end-of-life- and shared decision-making studies and adapted to the Norwegian context and the current study. Paper questionnaires will be used for patients, the next of kin can choose between paper and digital questionnaires and digital questionnaires will be used for the clinicians. The patients will be offered assistance in filling out the questionnaire by a staff not involved in the treatment of the patient. The inclusion of participants will start approximately 13 months after the start of the intervention in the implementation arm.

Patient outcomes

Questionnaire.

Patients in the triadic sub-study will be asked to answer a short questionnaire including the following dimensions:

Quality of communication and decision-making for the patient and the next-of-kin when approaching the end of life (primary outcome for patients)

Communication about preferences for information and involvement, health care personnel’ current compliance with these preferences, and trust in future compliance

Satisfaction with information about the patient’s state of health, discharge, prognosis, and future health care needs, and with information and involvement concerning health care provided during and after admittance

Self-efficacy in communicating with next-of-kin and health care professionals about future deterioration, about preferences for life-prolonging treatment in such a situation, and about health care when approaching the end of life

Problem causing admittance being solved; satisfaction with arrival, stay, and discharge at the hospital; and trust in necessary health care in the future

Concrete preferences for information and who should participate in important decisions about health care, and assessment of the amount of information given

General life satisfaction [ 48 ]

Demographic information

Data from patient health records

The researchers will retrospectively go through the patients’ electronic health records, given sufficient project resources. We will collect documentation from 18 months before to 18 months after inclusion (or until death) on the following: ACP and other similar conversations, palliative care plans, life prolonging treatment and palliative care given, any decisions to limit such treatment or care, and the patients’ life stance or religious beliefs.

Data from national registries

The patient dataset will be coupled to individual data from national registries (from 18 months before to 18 months after inclusion (or until death). This allows description of the patient population and their use of health services, and to assess possible long-term effects of ACP. The registers include the Norwegian Registry for Primary Health Care, Norwegian Patient Registry, Norwegian Prescription Database and Norwegian Cause of Death Registry.

Next-of-kin outcomes

Next of kin in the triadic sub-study will be asked to answer a questionnaire including the following dimensions:

Quality of communication and decision-making for the patient and the next-of-kin when approaching the end of life (primary outcome for next of kin)

Satisfaction with information about the patient’s state of health, discharge, prognosis, and future health care needs, and with information and involvement concerning health care provided during and after admittance, and with the health care personnel’ understanding of the next-of-kin’s situation

Self-efficacy in communicating with the patient and health care professionals about future deterioration, about the patient’s preferences for life-prolonging treatment in such a situation, and about health care when the patient is approaching the end of life

Problem causing admittance being solved, satisfaction with arrival, stay, and discharge at the hospital, trust in necessary health care for the patient in the future, and believe that you have to ensure that the patient receives needed health care in the time to come

Next of kin’s concrete preferences for information and assessment of the amount of information given, the patient’s preference for information and who should participate in important decisions about health care

Next of kin’s tasks and burdens

Informal carer’s care-related quality of life [ 60 ].

General life satisfaction [ 48 ].

Attending clinician outcomes

Attending clinicians in the triadic sub-study will be asked to answer a questionnaire including the following dimensions:

Clinical information about the patient

The professional role towards the patient

The patient’s concrete preferences for information and who should participate in important decisions about health care, and assessment of the amount of information given (primary outcome for attending clinicians is the congruence between the clinician’s answer and the patient’s answer on these questions)

Self-confidence in matching involvement of patient and next-of-kin and future decision-making to patient’s preferences

Self-efficacy in communicating about: future deterioration, preferences for life-prolonging treatment in such a situation, future care (at home or in a nursing home), and about health care when approaching the end of life, with the patient, next-of-kin, and other health care personnel

Recruitment

A local research coordinator at each participating unit will recruit participants assisted by the health care personnel at the units, guided by a set of instructions and supervision by the researchers. All potential participants will be assessed for eligibility. The patients who fulfil the criteria will receive verbal and written information about the study from a health professional at the unit. If a written informed consent is obtained, the health professional will ask the patient for permission to contact the closest relative to inform and possibly obtain consent and include him or her, and subsequently inform and recruit the clinician. The patient, the next-of-kin and the clinician will be included if the whole triad consents to participate. At the time of submission of this manuscript, the units were just about to begin recruiting participants to the triadic sub-study.

Data analysis

Demographic and clinical data about the patients will be used to assess whether the patients in the control and intervention units are comparable. In addition, the participating units will collect basic and anonymous clinical information about all patients admitted to the units at shorter random time periods, to get more information about the participant units and to compare the included patients with all admitted patients.

Number and percentages of invitation to and participation in ACP for patients and next of kin will be calculated and compared between intervention and control group. The primary statistical analyses will be the difference in mean outcomes between participants in the intervention and the control group using linear mixed effects models. The random part of the model will consist of random intercept for patient or relative identification nested within centre. Missing data will be handled by multiple imputation using predictive means matching with 100 imputed data sets.

If the analyses show differences in the intervention and control arm, we will perform analyses to assess if higher fidelity score (higher levels of implementation) is associated with improved outcomes for patients, next of kin, and clinicians. For the secondary outcomes, we will compute average outcomes and SD for the intervention and the control group and use the t-test to determine if there is a significant difference between groups.

Questionnaires to all staff

In this sub-study we will invite all health care personnel and leaders who are eligible from all participating intervention- and control units. The inclusion criteria are health care personnel (medical doctors, nurses, care workers, occupational therapists, physiotherapists, speech therapists), and leaders employed or attached to the unit in a 20–100% position.

Data collection and outcomes

A digital questionnaire based on validated questionnaires [ 41 , 43 , 61 ] will be administrated at baseline and 18 months after the start of the intervention. This will provide data both to investigate the status at baseline and to evaluate possible differences in changes between the two study arms. The questionnaire includes the following dimensions:

Patients’ and next of kins’ preferences for information and involvement

Whether information, involvement and health care provided is concordant with the patients’ and next of kins’ preferences and reasons for discordance

Decision making authority – clinical realities and ideals

Self-efficacy and confidence in ACP-relevant information and involvement tasks

Demographic information about the participants

For the baseline data, we will perform descriptive analyses, and compute average outcomes and SD for the intervention and the control group and use the t-test to determine if there is a significant difference between groups. For the follow-up-data we will compute average outcomes and SD for each point of time and treatment group and test the mean difference in change between the intervention and the control group from baseline to 18 months using t-tests.

Qualitative evaluation of ACP and of the implementation support

After 14–16 months of implementation support, we will perform focus group interviews with health care personnel in the intervention units and focus group interview with each implementation team in the intervention units. From month 4 to 14, we will conduct individual interviews with 10–12 patients and 10–12 next of kin who have participated in ACP. Through these interviews, we will get in-depth data relevant to all the secondary objectives, and in particular 3, 4 and 5: Barriers to, facilitators for and experiences with implementing ACP, including moral dilemmas and conflicting interests related to ACP, and benefits and disadvantages related to ACP and the implementation support. For patients and next of kin, we will also explore experiences with information, involvement in decision making and satisfaction with the health services, for health care personnel we will also explore attitudes, confidence and competence in giving information to and in the involvement of patients and their close relatives when the patient is approaching the end of life.

The qualitative data will also be used in the responsive evaluation process, together with input and notes from network meetings with the local coordinators, trainers, and managers in the intervention units when they share their experiences on the same main topics explored in the interviews. We expect that implementing ACP involves multiple and complex barriers (e.g. prioritisations, the risk of over- and under treatment, differences in stakeholder perspectives and beliefs, who should decide what). After identifying key barriers and facilitators, we will include these findings in the training program and didactic material (web-based and paper-based), and – together with the stakeholders – we will develop and refine relevant tools to handle barriers that may prevent ACP. One example is a deliberation method, developed by the researchers in this project, which can be used to better handle dilemmas related to end-of-life care and shared decision-making [ 62 ]. The training and tools developed will be evaluated as an important part of the implementation intervention.

Qualitative evaluation of barriers and facilitators for ACP in a broader context

The first qualitative sub-sub-study on barriers and facilitators in a wider health care service context was performed at baseline to inform the project and the development of the implementation strategy. Informants with special knowledge or experience with ACP or similar interventions were selected through a combination of a purposeful and snowballing method. Of 40 health care professionals and chief physicians in hospitals and community services, three had practiced ACP. Policy development, public and professional education, and standardization of documentation were reported as key factors to facilitate ACP and build trust across the health care system [ 53 ].

The second qualitative sub-study of ACP in a broader context is based on interviews conducted between May 2022 and June 2023, among stakeholders responsible for, or who may give important input to ACP policymaking and large-scale implementation of ACP at the municipal, regional and national level. We conducted a total of 15 interviews with health politicians on a national level, national health authorities, high-level leaders in both the hospital and municipal health care system, professional associations, user- and interest organizations, as well as leaders of health care educations. Relevant topics may be formal factors such as policy formulation, regulatory frameworks, financial arrangements, health educations, or other overarching structural incentives and barriers, and informal factors such as power relationships, conflicts of interest, knowledge traditions, norms, and values, coordination and collaboration across health care services, and barriers and facilitators within the various health care services at the organizational or clinical level.

Qualitative data analysis

For all the qualitative sub-studies we use semi-structured interview guides adapted to each stakeholder group. All interviews will be recorded and transcribed verbatim. The main analytic strategy will be a thematic analysis inspired by Braun and Clarke [ 63 , 64 ], using the topics and questions in the interview guide as a starting point for the analyses, as well as relevant theories from implementation and social science, ethics, and relevant policies.

Health economics

The economics analysis includes estimation of healthcare utilization, costs and cost-effectiveness of ACP and the implementation support in geriatric hospital units compared to standard of care. We will identify the resource use and costs related to implementing and conducting ACP in clinical practice, and we will estimate patient’s healthcare utilization and costs in order to identify differences in pathways as a result of implementation of ACP. Higher costs after implementation may indicate underutilization and lower costs may indicate overutilization of healthcare without ACP. The information on healthcare utilization will be collected from national registries covering both pharmaceuticals and primary, secondary, home based and institutional based care.

Resource use and healthcare utilization will be summarized over 18 months prior to inclusion in the trial and 18 months after. Total costs will be calculated, and we will use regression analysis to estimate the effect of ACP on total costs, also adjusting for individual characteristics, such as age, gender, comorbidity, living situation, social network, marital status and education measured at inclusion. We will also estimate the cost-effectiveness of implementation of ACP compared to standard of care. The costs will include intervention costs of ACP and the cost of the hospital stay. Differences in costs will be compared to the primary outcomes (measured as percentage point difference in quality of communication and decision-making for patients and for next of kin, congruence (attending clinicians) and fidelity (implementation outcome) and selected secondary outcomes. We will use the incremental cost-effectiveness ratio, defined as differences in costs between implementation of ACP compared to standard of care divided by percentage difference in primary (selected secondary) outcomes (ACP and standard of care). Uncertainty will be estimated by bootstrap methods and displayed in a cost-effectiveness plane.

The project will be evaluated comprehensively, and the sub-studies described below will be published in international scientific journals. We will also work to incorporate important knowledge and experience with ACP gained through the project to the curriculums for health care personnel and relevant national guidelines.

Data management and monitoring

The University of Oslo has signed contracts on shared responsibility for data processing with each participating Health Trust, which details the responsibilities for data collection and storage in accordance with Norwegian legislation and the General Data Protection Regulation. Since the Norwegian ACP trial is a minimal risk trial, we do not have a data monitoring committee. Project members will monitor the recruitment process and participate and monitor the data collection and have signed a similar contract to ensure conformity with the trial’s ethical and methodological standards. Data will be stored in a secure database, developed by the University of Oslo to collect, store and analyze sensitive research data in a secure environment “Services for sensitive data” (TSD). Only project members (researchers and scientific assistants) have access to the secure project area.

For the digital questionnaires, the respondents will fill out the questionnaire in the electronic “nettskjema”-application by UiO, which encrypts and stores the answers directly in TSD. Patients will in addition have the option to fill in questionnaires on paper. The participating institutions will collect consent and data from patients and next of kin in their respective institutions and be responsible for data management until delivered personally to a member of the project group for import to TSD. Paper questionnaires and consent forms will be stored in locked cupboards, whereas code lists with personal information will be safely stored digitally in secure databases in the Hospital Trusts. All participating institutions have appointed a research coordinator responsible for data collection and safe storage at each site.

Individual interviews and focus groups will be audio recorded with digital recorders and transferred to TSD via UiO-computers the same day; or with a secure voice recorder app developed for phones by UiO, which encrypts and transfers the interview directly in TSD.

Research ethics

The study was approved by Norwegian Agency for Shared Services in Education and Research (SIKT) with registration number 805491 and by local data protection officers at each trial site. Important protocol modifications will be reported to SIKT and communicated to the participating units, and the trial registry at clinicaltrials.gov will also be updated. The project will follow the Norwegian personal data legislation and regulation, the Norwegian Health Research Act, the guiding principle of the Declaration of Helsinki [ 65 ], as well as ethical standards as described by The National Committee for Medical and Health Research Ethics (NEM) and Committees for Medical Research Ethics (REK), e.g., about informed consent, privacy, and subject withdrawal.

Hospitalized patients and their next-of-kin can be considered a particularly vulnerable group. Special attention will be paid to assessment of capacity to consent and will only include participants with capacity to decide to participate in research. Thorough oral and written information will be provided, and written consent will be obtained from all participants. The participants can withdraw from the study at any time without giving any reason. Neither participation nor non-participation in the research will have any consequences for patient treatment, including to be invited to ACP.

This project is a contribution to a shift in the health services towards including a holistic patient perspective and to ensure patient-centered care in the management and treatment of older adults approaching the end-of-life. This will be the first trial to develop and test an intervention to improve the implementation of ACP for acutely ill and frail older adults in geriatric hospital wards in Norway. This complex multicenter project is both an implementation and an intervention study, which requires a mixed methods approach and measurement of outcomes on multiple levels [ 26 , 27 ]. The pragmatic cluster randomized design allows comparing outcomes between intervention and control arm on implementation- and service level, by measuring fidelity scores, as well as patient and relative level, by questionnaires, patient record data and health registers.

The ACP interventions in the intervention arm will be compared to treatment as usual in the control arm. Although the control clusters in theory may implement ACP during the project period, we consider this unlikely, due to the lack of incentives and the complexity of the intervention. What we do know, however, is that elements of ACP are used in communication with patients and their relatives in geriatric units already, although not systematically. Improving routines and quality of existing communication may not result in large differences in outcomes for patient- and next of kin in the intervention- and control arms. To prevent contamination between the control and intervention groups, we randomize participants at a cluster level, each cluster representing hospital units with distinct catchment areas.

There is a need for rigorous methods for defining and monitoring quality of implementation of evidence based practices (EBPs) [ 58 ]. This is of particular relevance for ACP and other practices where the implementation is low [ 6 , 9 , 15 , 23 , 30 , 66 , 67 ]. Fidelity of implementation is mostly not reported in ACP studies. There is also currently an absence of benchmarks or minimum standards for implementing ACP against which a comparison can be made [ 17 ].

We have developed the first validated ACP fidelity measure to improve both ACP research and implementation, with subscales that assess the implementation level, penetration rate and the content and quality of the ACP. This trial is thus a contribution to how ACP can be defined and assessed comprehensively as an EBP. It also incorporates a standard on how to implement ACP for all stakeholders. Hence this is also a contribution to a unified approach which is lacking in the field of research [ 30 , 67 ].

The project has a strong focus on sustainability and feasibility, such as assisting the clinical units to incorporate selected implementation interventions into their routines, procedures and day-to-day practice. We emphasize a whole ward approach, as the focus on education and staff competence is suggested as important for a sustainable ACP intervention that lasts beyond the active implementation phase of a research project [ 68 , 69 ]. We have already found that the lack of time and misconceptions about ACP are main barriers to ACP at the clinical level. Providing practical training for health professionals, particularly regarding how to start ACP, are important facilitators [ 53 ]. At institutional level, standardizing how to document and communicate ACP across levels were reported as the most important facilitators, and will therefore be among the implementation strategies where the project will strive to develop sustainable solutions.

ACP outcomes are influenced by the systems’ complexity, and evaluations need to consider the context. A major strength of this project is that the project design emphasizes strong stakeholder involvement before, during and after the project. The health care personnel, the frail older adults, their next of kin, the services and health administrators, and the policymakers will play an important role in the development of effective implementation strategies and optimizing the implementation and clinical interventions, e.g. as experts by experience in the local training and as stakeholder/co-researchers and informants. Together with the formative evaluation we will use qualitative method alongside the CRCT, as studies involving both CRCTs and qualitative research can give insights that is useful for understanding variation in outcomes, the mechanism by which interventions have an impact, and identifying solutions [ 70 ] . The value of qualitative research alongside a CRCT and of formative evaluation may contribute to optimizing the intervention and may improve the implementation. Additionally, the data will provide information and can be used to explore the feasibility, acceptability and implementation of the intervention to help understand how it was, or why it was not effective [ 71 ].

There is little or no research assessing whether the content from the ACP follows the patient and is used when the patient is transferred to another level of health care. Further, there is more limited research on ACP in primary care. This is a paradox, since family physicians have a central role for all patients in providing, coordinating, referring and planning of health care services, and could have the opportunity to initiate or follow up ACP [ 72 ]. A family physician who knows the patient well can play an important role in ensuring the intended consequences of ACP for the frail older adults and their close relatives. It is a limitation of this trial that we implement ACP in hospital wards, without an active focus through the research or implementation strategies on collaboration between health care levels or on follow-up of the conversations in the primary health care. The rationale behind selecting geriatric wards was mainly that Norwegian hospitals and Norwegian general practitioners by large are unfamiliarised with ACP, and we regarded the culture in the geriatric milieu as a natural starting point. Hopefully, further research and implementation will result in ACP at all levels, including the collaboration between levels.

The project outcomes, when interpreted in context, may be valuable across nations with both similar and diverse welfare services and health laws, e.g. to improve the implementation of evidence-based knowledge and ACP for frail older adults. Our approach fills an evidence gap critical to health service planners, and the lesson learnt from this project can enable recommendation for future services. The qualitative study of barriers and facilitators for ACP at the Organizational- and System level and the health economic analysis are contributions to lift the implementation of ACP to a broader societal and public health perspective. Our project may provide valuable knowledge to the fields of ACP, geriatrics, shared decision-making in frail older adults, health service research and implementation science. Furthermore, the project will illuminate critically and informatively the different stakeholder’s needs and difficulties with ACP.

Availability of data and materials

Not applicable.

Abbreviations

  • Advance care planning

Confidence interval

Centre for medical ethics

Cluster randomized controlled trial

Evidence-based practice

Intra-class correlation coefficient

The national committee for medical and health research ethic

Regional committee for medical and health research ethics

Standard deviation

Norwegian agency for shared services in education and research

Standard protocol items: recommendations for interventional trial

Tjenester for sensitive data

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Acknowledgements

The authors would like to thank professor Arnstein Finset for his contributions to integrating and strengthening the aspects of clinical communication in the intervention. Additionally, we would like to thank Pål Friis for important contributions to the conception and design of the study, and Hilde Aaneland and Hege Beate Ihle-Hansen for contributions to development of the intervention and of sub-studies.

Open access funding provided by University of Oslo (incl Oslo University Hospital) The study is funded by The Research Council of Norway (2020). The funding body is not involved in the design, running or reporting of the trial.

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Maria Romøren, Trygve Johannes Lereim Sævareid, Linn Brøderud, Siri Færden Westbye, Reidun Førde & Reidar Pedersen

Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway

Maria Romøren

Department for Health Sciences in Aalesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Aalesund, Norway

Karin Berg Hermansen & May Helen Midtbust

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Astrid Klopstad Wahl & Lisbeth Thoresen

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Contributions

RP, EA, MA, RF, MR, SR, TJLS, LT and AKW have made significant contributions to the conception and design of the study and developed the original research protocol. RP, MR, KBH, TJLS, LB, SFW, AKW, LT, SR, RF, MA, EA and MHM have made substantial contributions to the further development of the intervention and the study design including questionnaires and interview guides. MR wrote the first draft of this article, with major contributions from RP, KBH and TJLS. All authors have critically revised and finally approved the article.

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Correspondence to Maria Romøren .

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Ethics approval and consent to participate.

The study was approved by Norwegian Agency for Shared Services in Education and Research (SIKT), with registration number 805491, and it was in addition approved by local data protection officers at each trial site. The study was first assessed by the Regional Committee for Medical and Health Research Ethics (ethical committee: REK Sør-øst D), reference number 457837 which deemed the study outside of their scope of responsibility because it was regarded as health service research rather than health research. It was subsequently transferred to and approved by SIKT, which for health service research has the function of an ethics committee and takes care of the external ethics review in this study. The project follow the Norwegian personal data legislation and regulation, the Norwegian Health Research Act and the guiding principle of the Declaration of Helsinki. Written informed consent to participate in the study will be obtained from all participants.

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Supplementary Information

Additional file 1..

 The SPIRIT checklist. A completed SPIRIT checklist for the trial protocol.

Additional file 2. 

The ACP intervention. Detailed description of the trial’s intervention.

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Romøren, M., Hermansen, K.B., Sævareid, T.J.L. et al. Implementation of advance care planning in the routine care for acutely admitted patients in geriatric units: protocol for a cluster randomized controlled trial. BMC Health Serv Res 24 , 220 (2024). https://doi.org/10.1186/s12913-024-10666-0

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NCH among top 2% in nation, top 50 hospitals for surgical care by Healthgrades

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Aerial photo of College of Dentistry Building

UI seeks permission to plan second west side parking ramp

As the University of Iowa and UI Health Care look ahead to the additional staff and patients a new inpatient tower will bring to the west side of campus, so too will come the need for more parking.

The UI will ask the Iowa Board of Regents at its Feb. 28 meeting for permission to proceed with planning an additional parking ramp on the west half of the parking lots adjacent to the College of Dentistry building.

map of the proposed parking ramp in the dental lot

If it moves forward, the project would not begin until the new Hawkeye Parking Ramp , under construction north of Kinnick Stadium, is completed later this year or in early 2025. 

“The new hospital tower will bring more people—including patients, visitors, and employees—to that area of our campus and it will be important for us to be prepared for that,” says Rod Lehnertz, senior vice president for finance and operations. “In addition, being able to provide parking that is near the hospital complex is an important part of recruiting the staff needed to care for our patients.”

The proposed new ramp, which would include 1,000 to 1,200 spaces, along with reconfiguring the east part of lots 33, 40, and 44, would provide a net increase of about 800 spaces.

Adding a new ramp near the College of Dentistry building also will create more parking for the dental clinics and athletics events at nearby Carver-Hawkeye Arena. 

The preliminary estimated project budget, should the university decide to move forward with construction, is $55 million to $60 million.    

Also underway: Relocating the water tower

Another key enabling project for the new inpatient care tower is underway on the west side of campus.

The university’s utility partner, ENGIE North America, has begun working on the underground utility improvements necessary to build a new, larger water tower northwest of the football practice fields.

The new water tower will replace the current water tower located along Hawkins Drive near the main entrance of UI Hospitals & Clinics, which will need to be removed to make way for the new inpatient care tower.

The current water tower won’t be removed until the new water tower is built and fully functioning because it provides water storage for the entire campus. 

WFTS - Tampa, Florida

Members of small Baptist church question Florida megachurch's sale of property

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PALM RIVER, Fla. — A rezoning hearing is scheduled to take place Tuesday to consider a multi-million dollar proposed land development project that would build townhomes on the site of a long-time community church.

The property is now owned by a megachurch that acquired it through a merger a decade ago.

But the I-Team has learned members of the original church oppose the deal based on restrictions their leaders put on the original deed.

“God’s Country”

First Baptist Church of Palm River sprang from hope and faith starting in 1926 on a seven-acre lot near Palm River.

In the decades that followed, the church grew into a three-building campus paid for with members’ monthly tithes.

“It was weddings, funerals, baby dedications, Baptisms,” said Robert Almand.

image (5).png

Almand grew up half a block from the church and attended the church for more than five decades.

Guy Hays, another member, joined during the COVID pandemic.

“Everybody loves you like family. You don’t get that in a lot of churches. But this church right here, they showed the love,” Hays said.

Former members say the church loved not only members of the congregation but also those living nearby, partnering with Metropolitan Ministries to operate a community resource center.

image (4).png

Together, the church and non-profit provided meals for more than 200 people each week.

Neighbor Felicia Skrypek says she often relied on the church’s assistance.

“Food, clothing, you name it. Anything you ask for, they’re always there to help. Prayer, comfort,” Skrypek said.

Church mergers under “Restrictive Covenant Deed”

In 2013, as the buildings aged and membership began to dwindle, Palm River Baptist hoped to breathe new life into the church by becoming a satellite campus of Bell Shoals Baptist Church of Brandon.

That church is considered a “megachurch” and at one time claimed to have more than 8,000 members.

“Before they merged, the trustees of First Baptist of Palm River got together and created a restrictive covenant deed to protect property from being sold unless it was to another church,” Almand said.

image (3).png

The deed said the property “must be used for the express purpose of group worship in a church.”

It also said, “the property may not be used for or mortgaged or sold for any other purpose” and that the restriction could only be rescinded if “100 percent” of the church members agreed.

The deed also referenced the Southern Baptist Convention, the Florida Baptist Convention, and the Tampa Bay Baptist Association as stakeholders to make sure the wishes of the trustees of First Baptist Church of Palm River were carried out.

“There were no secrets. They knew the desire of First Baptist Church of Palm River to remain a church on this property,” Almand said.

He said Bell Shoals leaders were also aware the buildings had maintenance issues prior to the deed transfer.

Megachurch changes bylaws

In January of 2022, an amendment to the Palm River Church’s bylaws was filed with the Florida Secretary of State, saying, “Bell Shoals Baptist Church of Brandon shall be the sole member of this corporation.”

image (7).png

It was signed by Mark Hutchinson, whose title was listed as “Chairman of the Board.”

None of the former members of the First Baptist Church of Palm River knew Hutchinson.

Hutchinson is listed in state business records as a trustee of First Baptist Church of Palm River, Bell Shoals Baptist Church of Brandon, and Apollo Beach Community Church, which is another satellite campus of Bell Shoals Baptist Church.

“They turned the light out”

Bell Shoals' lead pastor, Dr. Corey Abney, met with Palm River members in early March 2022, saying he was closing the church.

Abney invited members to attend his church seven miles away, but most didn’t go.

Locked out of the Palm River sanctuary, they began worshipping in a nearby park.

“I asked him, can you give us several months,” said volunteer Palm River pastor Yves Johnson. “But that was not an option.”

image (9).png

“I always considered this church the lighthouse in the community. Bell Shoals, when they merged with Palm River, they became the lighthouse keeper. And they turned the light out,” Almand said.

In April 2023, a document rescinding the restrictions in the covenant deed was filed with the Hillsborough County Clerk of Courts office.

Deed restrictions removed by “unanimous vote”

It said a quorum of church members attended a meeting on Wednesday, April 19th, 2023, and by a unanimous vote determined “it is in the best interest of Bell Shoals, as the only member of First Baptist Church of Palm River,” to sell the property and remove “all the covenants and restrictions.”

“It wasn’t rescinded by our congregation, that’s for sure,” Almand said.

He said that, to his knowledge, he was never notified of the special meeting.

The church’s law firm, Carlton Fields, prepared a series of deeds involving all the interested parties.

On April 19 th , the same day the restrictions were removed, First Baptist Church of Palm River deeded the property to Bell Shoals Baptist Church of Brandon.

image (8).png

It was signed by Mark Hutchinson, identified on the document as the Chairman of the Board of Trustees of First Baptist Church of Palm River, and was witnessed and notarized by Dr. Abney’s executive assistant.

On May 4 th , 2023, Florida Baptist Convention, Inc. filed a quit claim deed releasing its interest in the property.

On June 8 th , the Tampa Bay Baptist Association filed a quit claim deed releasing its interest.

On June 28 th , the Southern Baptist Convention filed a quit claim deed releasing its interest.

The deeds were all prepared by the law firm representing Bell Shoals Baptist Church of Brandon, Carlton Fields.

We emailed and called Abney, asking him for an interview.

His secretary called us back and told us he declined.

Attorney Statement

A Carlton Fields spokesperson emailed us the following statement days later:

First Baptist Church of Palm River (Palm River) turned over complete control of its operations to Bell Shoals Baptist Church of Brandon (Bell Shoals) in 2014. Services and other activities at the former Palm River facilities ended in 2022 and those facilities were conveyed to Bell Shoals in 2023. At that time, the site of the former Palm River facilities was restricted to use as a Southern Baptist church. In 2023, that use restriction was lifted by Tampa Bay Baptist Association, Inc.; Florida Baptist Convention, Inc.; and Southern Baptist Convention. Documents reflecting the lifting of the use restriction were recorded in the public records of Hillsborough County. “The lifting of the use restriction followed a process approved both by legal counsel and by First American Title Insurance Company. It also was approved unanimously by the merged Palm River/Bell Shoals congregation. The lifting of the use restriction has allowed the sale of the former Palm River facilities site, the proceeds of which will enhance the mission and ministry of Bell Shoals.”

On November 11 th , Bell Shoals Baptist Church submitted a rezoning application for Lennar to build townhomes on the site.

The current proposal is for a 68-unit development.

A rezoning hearing is scheduled for Tuesday. If approved, the project will come before the Hillsborough County Commission in April.

Megachurch could receive millions from property

“I see it as a cash grab for them to sell this property to try to help pay off the debt at Bell Shoals Church,” Almand said.

Dr. Abney indicated that “to be debt free as a church” was part of its mission in a September 25 th , 2022, sermon entitled “Rethinking Rich: Mastering Your Money ” posted on the church’s YouTube site.

The Hillsborough County Property Appraiser values the Palm River property at almost $2.6 million.

Bell Shoals got the Palm River property free and clear.

A 2021 commercial mortgage agreement obtained by the I-Team shows Bell Shoals Baptist Church owed more than $11 million on its note.

“We want to see this church remain a church,” Almand said. “It’s not too late. God can work miracles.”

If you have a story you’d like the I-Team to investigate, email us at [email protected].

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New & Custom Home Builders in Elektrostal'

Location (1).

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Featured Reviews for New & Custom Home Builders in Elektrostal'

  • Reach out to the pro(s) you want, then share your vision to get the ball rolling.
  • Request and compare quotes, then hire the Home Builder that perfectly fits your project and budget limits.

Before choosing a Builder for your residential home project in Elektrostal', there are a few important steps to take:

  • Define your project: Outline your desired home type, features, and layout. Provide specific details and preferences to help the builder understand your vision.
  • Establish a budget: Develop a comprehensive budget, including construction expenses and material costs. Communicate your budgetary constraints to the builder from the beginning.
  • Timeline: Share your estimated timeline or desired completion date.
  • Site conditions: Inform the builder about any unique site conditions or challenges.
  • Local regulations: Make the builder aware of any building regulations or permits required.
  • Custom Homes
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What do new home building contractors do?

Questions to ask a prospective custom home builder in elektrostal', moscow oblast, russia:, find custom home builders near me on houzz, business services, connect with us.

IMAGES

  1. Real hospital planning in Project Hospital

    project hospital planning

  2. 5 Steps to develop a Hospital Masterplan

    project hospital planning

  3. 30+ Project Plan Templates & Examples to Align Your Team

    project hospital planning

  4. Hospital Project Consultancy

    project hospital planning

  5. how to build a new hospital ? hospital planning and designing,Hospital consultancy

    project hospital planning

  6. Healthcare Spaces of the Future: Smart Design, Healthier Patients

    project hospital planning

VIDEO

  1. Project Hospital: A Tutorial?

  2. What are the benefits of hospital renovation?

  3. Hospital Management

  4. Plan with me and Build Emergency Clinic

  5. Project Hospital

  6. Project Hospital History

COMMENTS

  1. Steam Community :: Guide :: Project Hospital: The Guide

    57 ratings Project Hospital: The Guide By BreachAndClear An up-to-date mid-late game guide, covering design 'philosophy', tips and tricks for each department, and my understanding from 300 hours of gameplay. I do not claim to be good at this game, but since I have nothing else to show for my 300 hour investment, writing this is the best I can do.

  2. PDF A PROJECT PLANNING GUIDE FOR HEALTHCARE FACILITY OWNERS

    Figure 3: Hospital Energy Use Areas 16 Figure 4: Hospital Water Use Areas 18 Figure 5: Cost Influence Graph 20 Figure 6: Top-level Phases of the PMBOK 27 Figure 7: Major Planning Phases 41 ... defines project planning from various perspectives, outlines healthcare specific project planning, and concludes with advice on how to be a good owner in ...

  3. PDF Understanding the Hospital Planning, Design, and Construction Process

    The first is the definition and planning for the hospital project itself, including the project request, strategic plan, facilities needs assess-ment, specific program, and concept design. Second is the preparation of schematic design, design development, construction documentation, and securing a building permit.

  4. A Primer on Project Management for Health Care

    How Does Project Management Work? Effective project management requires that the people involved in a project contribute through distinct roles, each with their own set of responsibilities: The project manager is responsible for planning, managing, and executing the project by engaging team members.

  5. Real hospital planning in Project Hospital

    1K Share 52K views 3 years ago #projecthospital #plasticswans Real hospital planning in Project Hospital Project hospital is one of the more serious hospitals sims on the market. I know...

  6. Tips for Healthcare Project Management

    Project management is a process of planning, organizing, and overseeing the work of a team to advance a specific organizational project and achieve an organization's objectives. Project management does not involve the routine day-to-day operations of an organization.

  7. The Guiding Principles of Hospital Design and Planning

    In this case, growth in number of beds, additional departments and the changing structure of population and healthcare needs should be considered during the planning phase of the facility. A good healthcare facility will last about 30 years or more. 3. Core is key. I start every design review around four key departments.

  8. Hospital Designing and Planning

    Hospital Designing and Planning Himanshu Bansal, Riya Mittal & Vijay Kumar Chapter First Online: 05 January 2023 528 Accesses Abstract For constructing an efficient hospital, we require some guiding principles and to go through a series of phases in planning and designing of hospital.

  9. Planning a hospital: What to prepare before designing

    The healthcare planner can assert the needs of the patient and clinicians, throughout design, coordination and construction process. Embarking on the design of a hospital project should not be underestimated, as indicated by the extensive and specialised preparation works involved.

  10. Project Hospital guide and beginner tips for 2020!

    Project Hospital guide and beginner tips for 2020! Really good guide! I definitely need to plan ahead more because I quickly lose cohesion as I expand, and suddenly people are having to walk long distances for everything. Only tip I would add is a bit of a shortcut... generally you will only ever get patients for departments you have built.

  11. Project Hospital Guide

    The Project Hospital guide is a collection of the best tips for this extremely complex strategy game. You will learn here how to manage the staff, which rooms / wards are the most important and how to care for patients and departments. The game guide to Project Hospital contains helpful information about single player mode that will let you ...

  12. Eleven Steps For A Successful Hospital Construction Project

    One Reply to "Eleven Steps For A Successful Hospital Construction Project". Chloe Fuchs. September 25, 2018. Gilbane's Public-Private Partnerships - A Year In Review 2023. Gilbane's Public-Private Partnership (P3) team achieved remarkable milestones in 2023. As Executive Vice President and leader of Gilbane Development Company's P3 ...

  13. Planning, Design, and Construction

    Aug 5, 2021 Join us and a panel of industry experts as we discuss solutions for common safety challenges during occupied healthcare renovations. From common pre-planning challenges like ICRA collaboration to challenges which often emerge within the first weeks of a project, such as dust and debris containment… Workplace Safety

  14. Everything you need to know about healthcare project ...

    Through project management, healthcare organizations take a project—like building a new hospital wing—from initial inception all the way to completion to achieve desired outcomes. The four primary stages of healthcare project management: Stage 1 - Initiation

  15. Hospitals and Health Centers: 50 Floor Plan Examples

    From our published projects, we have found numerous solutions and possibilities for health centers and hospitals depending on the site's specific needs. Below, we have selected 50 on-site floor...

  16. Hospital planning: challenges or opportunities?

    It is essential that the planning of hospital facilities responds to changing models of care and is undertaken through a genuine 'whole system' approach. Providing a fit for purpose patient environment across the health economy must be a key target for all commissioners and providers alike.

  17. Can we have better planning tools? :: Project Hospital General Discussions

    The point of the game is to build a building, but it doesnt provide any planning tool. The mistakes the players are going to make are because of lack of resources, and not because of genuine mistakes. But if the players are provided with planning tools, and then make mistakes, its entirely their fault. #5. Showing 1 - 5 of 5 comments.

  18. Hospital Architecture Design & Planning

    In the Concept Design we will provide the elevation of the Hospital Building, block relationships of the departments showing area, shape and location within the building and of the vertical circulation elements such as elevators and staircases and the layout of the horizontal circulation routes (corridors)

  19. Fears for waiting lists as Calvary Health pulls out of Launceston

    According to the project development agreement signed between the state government and Calvary in 2022, the $130 million hospital would have seen the creation of 168 new beds, 10 operating ...

  20. $1B plan off for new Buffalo hospital; renovations underway instead

    Eighteen months later, the VA system has more than $100 million in projects underway or designed for FY 2024 in Buffalo, where it operates a 1.1 million-square-foot hospital campus, plus as well ...

  21. Pair of Prince Albert projects show promise for city, but prices have

    The Prince Albert hospital project is expected to begin construction in the spring and be completed in 2028. $18-million loan approved for aquatic, rink facility ... Planning for millions from donors.

  22. Implementation of advance care planning in the routine care for acutely

    The aim of this project is to improve user involvement and health services for frail older adults living at home, and their relatives, by implementing advance care planning (ACP) in selected hospital wards, and to evaluate the clinical and the implementation interventions. This is a cluster randomized trial with 12 hospital units.

  23. NCH among top 2% in nation, top 50 hospital for surgical care

    NCH announced that it is one of America's 100 Best Hospitals for 2024, according to new research released by Healthgrades, the leading resource consumers use to find a hospital or doctor.

  24. UI seeks permission to plan second west side parking ramp

    If it moves forward, the project would not begin until the new Hawkeye Parking Ramp, under construction north of Kinnick Stadium, is completed later this year or in early 2025. "The new hospital tower will bring more people—including patients, visitors, and employees—to that area of our campus and it will be important for us to be prepared for that," says Rod Lehnertz, senior vice ...

  25. Climate change: Plan to capture, ship and bury power station's CO2

    The project is part of the wider South Wales Industrial Cluster (SWIC) plan. This involves major industries - responsible for about 40% of Wales' total greenhouse gas emissions - working together ...

  26. Exhibitor List 2021

    Other Projects; Contacts; Exhibitor List 2021. Back to exhibitor list Moscow Interregional Association of Chief Welders.Stand 81C07 ... Floor plan Press Release: Contacts. 9/1 Bolshaya Maryinskaya ul., Moscow 129085, Russia. E-mail: [email protected]. Phone:: +7 (495) 734 - 99 - 66.

  27. Members of small Baptist church question Florida megachurch's sale of

    Members of a small Baptist church that merged with a megachurch question the new owner's desire to sell property for a new construction project, saying a restrictive covenant deed prohibited its sale.

  28. Best 15 Home & House Stagers in Elektrostal', Moscow Oblast, Russia

    Search 21 Elektrostal' home & house stagers to find the best home stager for your project. See the top reviewed local home stagers in Elektrostal', Moscow Oblast, Russia on Houzz.

  29. New & Custom Home Builders in Elektrostal'

    Search 1,121 Elektrostal' new & custom home builders to find the best custom home builder for your project. See the top reviewed local custom home builders in Elektrostal', Moscow Oblast, Russia on Houzz. ... After planning and permitting work, the actual building of the home in Elektrostal' can take anywhere between 6 months and 2 years ...