Despite high unemployment among architects, MODERN HEALTHCARE's 1994 Design & Construction Survey shows a stable and optimistic market.
The uncertainty of healthcare reform as well as capital financing limits have delayed many projects, but those involved in healthcare construction are hopeful that reform will spark demand for new projects.
"This could be a great time for healthcare architects," said Julia Thomas, a partner with Los Angeles-based Bobrow/Thomas & Associates. "In many parts of the country, reform has already occurred or is occurring, and the planning and construction market shows this."
Reform initiatives will change the way healthcare facilities are designed-from technology and building codes to social attitudes and reimbursement regulations. Shifting the emphasis to managed care will trigger movements in the design and construction industries as well.
Other factors driving design and construction activity include the increase in mergers and consolidations, the need to modernize outdated facilities, the move to "patient-focused" care, and the continuing cutbacks in Medicare and Medicaid funding.
Facing change. One of the mostdifficult issues for many healthcare organizations is accepting change. Bobrow/Thomas currently is helping Cook County Hospital in Chicago prepare for its future.
"For the first time we are asking: What is the role of a county hospital?" said Ms. Thomas. Because of the reduced need for hospital-based acute care, the facility is concentrating on the deployment of resources and the creation of ancillary departments to deliver ambulatory care.
About 50% of Ann Arbor, Mich.-based Hobbs+Black's healthcare work is reorganization and consolidation of rural facilities, said Larry Frank, senior vice president of healthcare at the architecture firm.
"Today, our firm spends as many hours with our healthcare clients establishing strategic organizational issues such as new management, staffing efficiency options and new categories of service as we do with our departmental planning," Mr. Frank said.
The 500-bed Borgess Medical Center in Kalamazoo, Mich., is reorganizing its service structures as well as cross-training its support and nursing staffs. Borgess also is in the preliminary stage of planning a centralized outpatient facility on its main campus.
President Clinton's healthcare reform plan aims to expand access to the nation's healthcare system. That could accelerate the revamping of existing facilities and the construction of additional facilities to provide outpatient services to a larger portion of the population.
Meanwhile, as portability and modularity become more important in healthcare delivery, technology and equipment, facilities and furnishings also will need to be flexible to accommodate responses to mergers and an increase in the number of patients served.
The growing segmentation of the long-term-care market is demanding that facilities be redesigned, expanded or renovated as well, according to many architects and interior designers. For example, assisted-living residents require living space that's very different from that of skilled-nursing residents.
"(Our) role is to develop a cost-effective design appropriate to the resident population," said Margi Kaminski, a partner in QUARTERS/Designs For Living Spaces, Hinsdale, Ill., an interior design firm specializing in long-term-care facilities.
"I must take into account such factors as impaired mobility, visual acuity and the degree of assistance required for dining, socializing and bathing," she said.
Mergers and consolidations. Themost important change affecting facilities' master plans is the need to anticipate trends and plan design and construction around changes in market demands.
"With the consolidation of facilities, there will be less duplication of services and more cross-training of staff," said David Kuffner, senior partner for healthcare design at Deerfield, Ill.-based O'Donnell Wicklund Pigozzi and Peterson.
Construction companies are building fewer large, single-building hospitals and are working on more satellite facilities that are tied electronically to one another and a central processing building.
The 740,000-square-foot, 240-bed Kaiser Foundation Hospital's Baldwin Park (Calif.) Medical Center, for example, includes a seven-story patient tower, a four-story clinic, a three-story rotunda and a separate central plant. Located on 23.7 acres, the $119 million facility is one of the largest hospital construction projects in California and also is the largest hospital project ever for McCarthy, a St. Louis-based construction management firm. It's scheduled for completion in August 1994.
In Flint, Mich., four hospitals joined to form a 480-acre regional healthcare delivery system anchored by a new flagship facility. Ambulatory and outpatient services remain at each of the original sites to provide convenient, easily accessible care and to act as referral centers to the new flagship hospital.
Genesys Health Systems, formerly St. Joseph Health System, Flint, has designed its patient-focused health park around a mid-rise concept; buildings of four to six levels are horizontally organized with about 100 beds on each level-hospitals within hospitals. The system anticipates a 10% to 15% reduction in full-time-equivalent requirements through cross-training.
Physical integration, close proximity to offices and "drive-up" convenience for ambulatory components are other features. When done, the $180 million campus will be an integrated system that may include expansion into "self care," health maintenance, acute and critical care, and continuing care for chronic conditions.
"We are really seeing a revolution in the construction of healthcare facilities," said Richard Rantala, vice president of marketing at Dallas-based Centex Construction Group.
George J. Mann, professor of health facilities design at Texas A&M University, said, "Architects in the 21st century will plan entire regional networks and alliances of healthcare delivery systems, including communications, transportation and facilities."
In the planning stage.Reductions in
Medicare and Medicaid reimbursements coupled with the diminishing ability to shift uncompensated costs is establishing a strong incentive for facilities to concentrate on cost-saving techniques during the planning stage of construction.
"The only way facilities will be able to afford financing capital investments is to construct a delivery system that highlights quality of care in a cost-efficient manner," said Lynn Bonge, executive vice president at the Omaha, Neb.-based architecture firm Henningson, Durham & Richardson.
El Camino Hospital's Orchard Pavilion in Mountain View, Calif., opened in May 1993. It offers inpatient maternity and pediatric services, physician offices and subterranean parking.
Influenced by nearby Stanford University, where many physicians and board members have affiliations, the design of the building reinforced the campus-planning concept. The $30 million facility relies on a mixed-use design to accommodate physicians on two of the building's upper floors.
The arrangement encourages time efficiency and reinforces referral patterns, said Ken Lee of the Los Angeles-based architecture firm Lee, Burkhart, Liu.
The pavilion's innovative use of back-to-back nursing stations allows nurses to serve the post-partum unit as well as an adjacent pediatric inpatient unit during evening shifts. Because of traditional fluctuations in the pediatrics census, the firm was able to obtain a waiver of existing state code to achieve the nursing-unit configuration.
During low census periods, nurses can more easily "float" from one unit to another. Support functions can be shared, which is expected to reduce staff costs.
Modernization."We seehealthcare facilities courting primary-care physicians by building or modernizing medical offices," said Michael Arenson, a partner at Northbrook, Ill.-based Shayman Salk Arenson Sussholz & Co. "It is important to think of construction or renovation as an investment and remember that expansion or modernization helps to market the facility."
Modernization can be very costly. However, changes in delivery, such as a reduction in the number of certain procedures ordered, will require retrofitting or remodeling existing space.
"With the surplus of patient beds, often in the oldest portions of existing hospitals, the challenge will be to find appropriate and economical uses for these structures," said Tracy Calcaterra, marketing coordinator at St. Louis-based J.S. Alberici Construction Co. The general contracting company saw a 114% rise in total value of completed healthcare construction in 1993 to almost $48 million, of which $42 million involved hospital expansions and renovations.
Renovations require the precise evaluation of existing facilities and recommendations on the feasibility of reuse. Institutions must recognize the constraints of the facility to accurately assess proposed solutions, said Judy Little, marketing coordinator at the Southfield, Mich.-based architecture firm Harley Ellington Pierce Yee Associates.
In building additions, one critical issue is to avoid disrupting the hospital's ongoing activities.
The $35 million expansion at York (Pa.) Hospital was completed in September 1993 for high-tech delivery departments: surgery, emergency, cardiac care and neonatology. Maintaining access to the hospital's emergency department was vital. It handles about 60,000 trauma cases a year and was adjacent to the construction site.
McCarthy arranged precise construction sequences to ensure effective communication, utilization of innovative techniques and value engineering, said Walter R. "Bud" Guest, senior vice president.
Maintaining operations also is a priority in the construction of replacement facilities. For example, 30-bed Shriners Hospital for Crippled Children in Boston, built in 1969, had to be kept running while a new facility was being built on the site.
The project posed many challenges to design: a congested urban site, a neighborhood antagonistic to construction activity, and the need to observe special architectural considerations in a historic district.
A new $53 million facility is currently under construction. It's being built on top of the old one on a four-story, stilt-supported platform. When the new facility is finished, the old hospital will be demolished and that space will be filled in.
Scheduled for completion in July 1997, the replacement hospital will have the same number of inpatient beds but will have expanded outpatient and research departments, said Ted Nevells, project engineer at Barton Malow Co., Southfield, Mich.
Many providers are interested in a patient-focused-care concept that involves organizing the hospital's services, resources and personnel around patient needs. Designers of the 144-bed Copley-Rush replacement hospital in Aurora, Ill., have taken patient-focused care one step further.
Architect OWP&P teamed with John Trimble of Prairie Systems Corp. to use a computer program called Wheelchair Virtual Reality. They sat in a wheelchair connected to a computer with head-mounted displays that showed a stereoscopic view of the room on a computer screen.