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When Norton Healthcare, Louisville, Ky., set out to redesign a 373-bed acute care facility to meet the changing needs of its community, the organization “knew that we had the fiscal responsibility to think broader and think bigger,” says Charlotte Ipsan, RNC, NNP-BC, chief administrative officer, Norton Women’s and Kosair Children’s Hospital. “It’s a lot to spend $118 million,” she says. The challenge of the project became, according to Ipsan, “How do we build for tomorrow and take care of what we need today?”
To allow hospitals and health systems to make the most of capital investments and keep pace with changing care protocols, technology, demographics, reimbursement structures, regulatory environments and patient expectations, health care design professionals are working to create facilities with built-in flexibility to meet current and future needs.
Building for the future
Norton Women’s and Kosair Children’s Hospital, designed by HKS Inc., Dallas, with associate architects Laughlin Millea Hillman Architecture, Louisville, was unveiled in December 2014. The facility has several features that will enable the health system to adapt to changing health care requirements. While it currently treats inpatients, the oncology department is structured to care for both outpatients and inpatients, including acute leukemic patients and bone marrow transplant recipients transferring from distant facilities. A workout area is accessible to inpatients and outpatients for rehabilitative therapy, but the space can be converted to a patient room, if necessary. A variety of staff work areas in the unit include space in the patient room, just outside the room and at a more traditional nursing desk.
The neonatal intensive care unit (NICU) has a hybrid design intended to provide the privacy of single-patient rooms and the visibility of a more open layout. Rooms for the most critical patients include private areas for family members. Twins or triplets can be accommodated in the same room. Infants who are close to being discharged are cared for in an area with dividers that can be rolled in or out depending on whether families want privacy or the opportunity to learn techniques from other parents about how to care for their infants.
Because of continuing advances in the prevention of premature delivery, fewer neonates should require critical care, says Ipsan. With this in mind, the entire NICU is designed to adjust to a larger percentage of infants of later gestational age.
“It’s an extremely flexible area,” Ipsan says. What’s more, she adds, “We saved at least $3 million in the way we created this design. We were being fiscally responsible but, at the same time, we can serve far more patients … and be able to meet the need of whatever we may see in the future.” The emergency department (ED) has similar flexibility. The ED’s design allows for quick registration and treatment of patients, but the space can be converted easily into an immediate care center if Norton Healthcare determines that’s a better use of the space. Ipsan says the health system is very comfortable that the facility design will meet any future needs.
Investment in choice
“Flexibility is an investment in future choice,” says Heather Chung, associate AIA, LEED AP BD+C, EDAC, vice president and San Francisco health care planning studio leader for architecture, engineering and planning firm SmithGroupJJR. Mark Patterson, AIA, ACHA, EDAC, LEED AP BD+C, SmithGroupJJR’s health practice leader, based in the firm’s Phoenix office, adds that “It’s definitely a topic we address with every client, because of their interest in it and the responsibility they have for the capital investment.”
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Hospitals and health systems must weigh access to capital against competing project demands. Preparing for future change begins with strategic planning, says Simon Bruce, RIBA, associate AIA, vice president, SmithGroupJJR, from the San Francisco office. To target resources effectively, project teams should analyze possible scenarios and determine the future likelihood of implementing potential options that were made possible by the flexible design.
For Phase 1 of a replacement hospital project underway at an academic medical center in the southeast, the team spent eight months looking at different ways to populate the site and nearly 500,000 sq. ft. of construction, according to Jens Mammen, RA, vice president and medical planning leader, SmithGroupJJR, Chicago office. The team considered the performance characteristics of a variety of options and chose a modular design for the patient units that will allow for incremental changes on the bed floors, which are not expected to alter radically from one type of utilization to another. The diagnostic and treatment floors are designed for a greater degree of change over time. Mammen calls this approach “focused flexibility.”
By thinking of buildings as part of the continuum of care, hospitals and health systems can decide whether a larger up-front investment in flexible design or a smaller facility outlay, such as leasing clinic space, is more appropriate in a given situation, he says.
Meeting market needs
Scott Huff, senior associate in the Philadelphia office of design and consulting firm Stantec, says it’s helpful to prioritize what’s most important on a health care project: budget, patient experience, staff efficiency, speed to market or flexibility. He asks clients, “What does today’s market mean to you? What does this project need to do to be successful?”
For Philadelphia-area health system Main Line Health, the key priorities of a recent ambulatory care project were flexibility, patient experience and staff efficiency. The project team renovated 32,000 sq. ft. of underutilized space within an enclosed shopping mall — spanning about a dozen store fronts — to create Main Line Health Center, Exton Square. The health center offers primary care, specialty care, urgent care, laboratory, imaging, physical therapy and cancer treatment services. It features a universal layout. All 34 exam rooms are designed the same so that clinics can expand or retract in size depending on need.
PinnacleHealth, a hospital and health care system in central Pennsylvania, is implementing plans for expansion at multiple facilities and building a new hospital. The system is focused on enhancing its patient-centered and integrated approach to health care, leveraging ultimate flexibility in an effort to build no more square footage than necessary, Huff says. At PinnacleHealth West Shore Hospital, Mechanicsburg, speed to market and cost-effectiveness were additional primary concerns. The hospital, which opened in May 2014, took 24 months and one day from the time the design-build contract was signed to the time the first patient was seen at the facility, according to Huff. Standardization in the design helped to control the budget, made the facility easier to build and will simplify future changes. All patient rooms are sized for intensive care, and each floor is designed to expand horizontally. Also, operating rooms can be added without disrupting the newly built space. The ED, cardiac care and radiology departments can expand horizontally at grade.
Greg Hamilton, AIA, ACHE, NCARB, senior associate, also from Stantec’s Philadelphia office, says that ensuring a facility’s mechanical, electrical and plumbing systems are designed to be updated and modified easily is one of the best first-cost investments a hospital or health system can make toward future flexibility. Modular components, such as demountable walls or headwall systems, can be helpful, too, he says.
Organizational culture is also important to consider when making flexible design decisions, Hamilton notes. “Do you practice flexibility within your staff? Then your building can be more flexible,” he says. “If you’re going to make your building flexible and your staff aren’t flexible in their processes, we’ve found that it doesn’t work.”
PinnacleHealth West Shore Hospital demonstrates the connection between flexible staff and design with three patient bays on the edge of the ED that can be used for ED surge capacity or as holding bays for inpatients going to the adjacent radiology department. The area isn’t assigned to either department; rather, it is used and staffed according to need. And while the hospital has 108 private patient rooms, it has no private offices for the health care staff.
Health care is beginning to embrace the corporate workplace strategy of open-plan offices for a number of reasons, says Rick Hintz, AIA, ACHA, NCARB, LEED AP, health care regional practice leader from the Minneapolis office of architecture and design firm Perkins+Will. “The space savings, the teaming flexibility and the ability to provide touch-down stations via systems furniture that’s reconfigurable and capable of being depreciated over seven years, instead of a fixed asset, all are contributing to this,” he says.
As health care service venues become more decentralized, people need to be far more mobile, Hintz adds. “Technology has enabled us to not have to work at a desk in an enclosed room. You can work anywhere, almost, and connect with people in all kinds of ways.” Moving away from dedicated office space allows for more flexibility in both facility design and operations.
Jessica Wolkoff, planning and strategies consultant, Perkins+Will, says providing new work settings with design solutions like shared space for confidential work is critical to the success of an open office plan.
Team work space also helps to promote collaborative care. “The idea of a physician office way at the back and the nurse practitioner sitting up front is a thing of the past,” Hintz says. “They’re sitting as part of the care team. So, more of a flexible work environment is absolutely essential.”
At the Ann & Robert H. Lurie Children’s Hospital of Chicago, which was designed by Zimmer Gunsul Frasca Architects, Portland, Ore.; Solomon Cordwell Buenz, Chicago; and Anderson Mikos Architects, Oakbrook Terrace, Ill., the building’s 22nd floor currently houses offices. However, it has medical gas, electrical power, air handling and other infrastructure technology preinstalled so that it can be converted to a high-acuity bed floor if necessary, explains Greg Quinn, PE, LEED AP, principal and health care practice leader from the Chicago office of project engineers Affiliated Engineers Inc. The necessary infrastructure to allow the hospital’s imaging department to expand over time also is in place.
The facility’s laboratory is a completely open and flexible space. The intention behind this design is to enable laboratory personnel “to reconstruct their lines in the future however they want, within a certain level of parameters,” says Quinn. “We planned it within a certain geometry of space, certain number of column bays, certain square footage, but we did it as flexibly as possible.” The laboratory casework is on wheels, so it can be rearranged easily.
According to Quinn, there are several levels of flexibility hospitals and health systems can engineer into their facilities, from acuity-adaptable patient rooms to full interstitial mechanical floors. Installing infrastructure to handle catastrophic events or pandemic outbreaks also can increase a facility’s flexibility. A zoned air handling system at Columbia St. Mary’s Hospital, Milwaukee, for example, allows the hospital to run efficiently under normal conditions while maintaining significant surge capacity for negative-pressure isolation rooms in the event they’re needed.
“I think that we as designers and builders of the health care facilities of the future have some work to do to help our clients understand the true value of investing, on ‘Day 1,’ for what they don’t know. Particularly now, with the uncertainty in health care,” says Quinn.
“Clients should feel confident to challenge their planners and designers to look beyond ‘Day 1,’ because there are a lot of alternatives,” he adds.
Amy Eagle is a freelance writer based in Homewood, Ill., and a frequent contributor to Health Facilities Management.
Designs that can constantly evolve over time
Health care is a complex, adaptive, evolving system, notes James R. Kolb, AIA, LEED AP, health care design principal in the Jacksonville, Fla., office of design and consulting firm Gresham, Smith and Partners. Flexibility in facility design enables hospitals and health systems to pursue continuous improvement without continuous renovation.
“Things will never change this slowly again,” Kolb says. “If you are not constantly evolving, you will become obsolete.” Extensive renovations can be so expensive that replacement becomes a more viable solution to an outdated facility, he adds. “So, not accommodating evolution can drive you to a much more expensive resolution of the issue. That’s why these things are so terribly important for our clients, and why, as we look at any project, we’re trying to look past the immediate needs.”
At University of Florida Health North, Jacksonville, an ambulatory care and medical office complex that opened in February, the emergency, imaging and surgery departments on the first two floors have no hard barriers between them. This makes it easier to share resources and adjust to changes in the patient census. Physician offices are on the top four floors and less-acute functions can be moved to the upper floors if demand increases for higher-acuity care.
Flex space was built between key rooms in the facility’s interventional suites to support continued advancement in clinical technologies. “At one time, we would talk about surgery and interventional radiology — we’d think of those as distinct environments,” Kolb says. “Today, we typically think of them as one environment, and we understand there’s an evolving merger between open surgery, image-directed surgery and endovascular procedures.”
For a project currently in schematic design, Kolb is designing a two-level surgical platform that will accommodate 20 different interventional environments using a set of core models that can be adapted to a standard operating room, large operating room or hybrid interventional suite. “It creates an inherent initial flexibility, but it’s also going to create a good long-term flexibility,” he says.
Health care clients may ask for spaces designed to support a specific operational model. “If we give them that, we’ve left them short,” Kolb says. “We have to provide an environment that not only will meet those current needs, but has the ability to adapt or evolve or be used differently in the future.”
Standardization that helps to speed renovations
According to Catherine Corbin, vice president and Chicago health practice leader for design firm CannonDesign, there are three main things hospitals and health systems should consider if they want to design facilities flexible enough to adapt to operational or technological changes without major reinvestment. She and her colleague Mike Pukszta, AIA, principal and national health care practice leader, CannonDesign, note that such facilities can be more efficient to design and build in addition to being less costly to occupy over time.
The first is a comprehensive, high-level understanding of the patient base to be served by the facility. “You know that patient volumes are going to change, demographics will shift. You’re looking for big patterns,” Corbin says. This helps to determine the current state of the market and the direction in which patient and community needs are headed.
The second is the overall building size, scope and scale. Establishing a standardized structural grid allows designers to begin working within these parameters early in the project. “Once we know how many patients we’re serving and what types of services will be provided, we still don’t necessarily know where those activities or functions will occur in a building,” Corbin says. “But we can get started on design, and our clients are asking us to get started on design sooner and sooner in the process.” An underlying universal grid enables designers to anticipate the massing of the building, with the understanding that even if programmatic elements change, the superstructure is receptive to a variety of needs.
The third is standardizing room sizes and footprints. If rooms’ physical space requirements are similar, their internal functions can change easily. This approach was recently borne out in the design of a new ambulatory care center for OhioHealth, Columbus, which is scheduled to open this summer. “Midway through the design, the program for 20,000 sq. ft. of space completely changed,” Corbin says. “But because all the rooms were using roughly the same footprint, we were able to easily repurpose available area, and it didn’t negatively impact the schedule.”
In addition, says Pukszta, a standardized 18-foot floor-to-floor height allows tradespeople to install infrastructure systems above the ceilings of a building concurrently rather than sequentially, providing a speed-to-market advantage and sizable labor savings during construction — significantly more than enough to offset the cost of additional materials. For example, at Kaleida Health’s Gates Vascular Institute, Buffalo, N.Y., the return on investment was $500,000 per floor — or $10 per sq. ft. — for mechanical, electrical and plumbing trades, due to ease of installation and coordination across four floors of clinical space.
At last count, CannonDesign has utilized the firm’s trademarked Universal Grid Theory on 9 million sq. ft. of building area, with millions more under construction, Pukszta says. Among the most recent of these projects is Northwestern Medicine’s 259 E. Erie St. building, a 26-story outpatient surgery center and patient care pavilion that opened in Chicago last October. The structure is designed to support a number of operational layouts.
Corbin notes that providers, particularly medical specialists, can be concerned that universal design won’t meet their specific needs. Thoughtful conversations with practitioners can help them to appreciate that “universal doesn’t have to be generic. Universal actually can mean adaptable,” she says. “As their practices change, as their patient needs change, those universal rooms can adapt to those changes much better than a highly customized space.”