Framing the Issue
• Hospitals today are especially challenged to use their investments in new facilities wisely.
• Hospitals must meet today’s patient demands and be ready to change quickly as everything from treatments to technology to reimbursement changes, and continues to change.
• Architects are designing spaces that can be converted back and forth from inpatients to outpatients, from critical care to rehabilitation therapy, from exam rooms to registration bays.
• As one design expert says, “Flexibility is an investment in future choice.”
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, chief administrative officer, Norton Women’s and Kosair Children’s Hospital. “It’s a lot to spend $118 million.”
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 creating facilities with built-in flexibility to meet current and future needs.
Norton Women’s and Kosair Children’s Hospital, designed by HKS Inc., Dallas, with associate architects Laughlin Millea Hillman Architecture, Louisville, was unveiled last December. 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 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, “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 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, vice president and San Francisco health care planning studio leader for architecture, engineering and planning firm SmithGroupJJR. Mark Patterson, 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.”
Hospitals must weigh access to capital against competing project demands. Preparing for future change begins with strategic planning, says Simon Bruce, vice president in SmithGroupJJR’s 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 square feet of construction, according to Jens Mammen, 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 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.
PinnacleHealth, a 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, senior associate, also from Stantec’s Philadelphia office, says that ensuring that 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 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, 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 of Portland, Ore., Solomon Cordwell Buenz of 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 pre-installed so that it can be converted to a high-acuity bed floor if necessary, explains Greg Quinn, 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 laboratory is an 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.
According to Quinn, there are several levels of flexibility hospitals 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.” — Amy Eagle is a freelance writer based in Homewood, Ill.
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.
1 | 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.
2 | 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.
3 | Standardizing room sizes and footprints
If the physical space requirements of rooms are similar, their internal functions can change easily. This approach recently was borne out in the design of a new ambulatory care center for OhioHealth, Columbus, which is scheduled to open this summer. Because all rooms have the same footprint, there was minimal disruption when plans completely changed.