When Kell West Regional Hospital, a small general hospital in Wichita Falls, Texas, was built in 1998 with 15 beds, its investing doctors used an outside firm as project manager. But three years later, when 30 of the doctors underwrote an expansion to double Kell West's space, hospital Chairman Jerry Myers, M.D., became his own project manager.
The role of project manager--overseeing architects, builders and other contractors--usually goes to a seasoned professional. Healthcare consultants discourage doctors from taking on the role, arguing that the loose ends of such a complex project can slip through a busy doctor's fingers.
"You just have to be a little crazy to take this on," Myers admits, but he says the work went smoothly, even though he maintained his clinical workload.
In fact, he says his clinical experience gave him clear ideas of how everything should be constructed and arranged throughout the $4.5 million project, down to the smallest piece of equipment in the operating room.
Also, he says wanting tight control over building the hospital flows naturally from the reason he and other doctors founded the facility--wanting tight control over hospital operations, from admissions to operating room time, which they could not have at the local acute care hospital.
And perhaps most crucially, Myers did not have to contend with objections to his role from an outside partner, because his doctors own 100% of the hospital.
Physicians are building
Though there are no precise statistics, healthcare developers report that physician-initiated building projects--ranging from surgery hospitals to ambulatory surgery centers to physicians offices--are a big part of healthcare construction these days.
As reimbursements stall, "physicians are looking for ways to enhance their revenues as well as make things more convenient for the patient," says Becky Smith, an architect with LS3P Associates in Charleston, S.C.
Saddled with income constraints, physicians who launch construction projects are trying to keep building costs down while adding space for new, income-generating equipment and using designs that maximize staff efficiency, she says.
"It's a tough balancing act," and it requires a professional, she says.
Every healthcare architect seems to have stories about doctors who demand control of a building project. "There are some physicians who think they know everything, and in their other life they would have been architects," says another Mid-Atlantic architect, who asked not to be identified.
That architect says she had to drop a surgeon as a client because it was impossible to work with him on an ASC he was planning.
"He would call me and say, 'I talked to 23 of my friends and they all said you should do this,"' that architect says. "It turned out it took him three years to do the project. I could have done it for him in 12 months and saved him a lot of money."
A physician takes charge
But Myers says he had good relationships with his professional consultants and had some experience under his belt from building the original Kell West hospital with Leland Medical Centers, a developer in Dallas.
When the hospital outgrew its space and the doctor-owners decided to build a 30,000-square-foot wing, adding 26 beds, Myers says he was ready to be the project manager.
Whether managing or not, "you need a lead physician in this, someone who will do all the legwork," he says.
During planning, he says he consulted with a construction steering committee made up of four other Kell West doctors, as well as the lead banker financing the project and an accountant.
"Decisions need to be made on the fly, so you need a core group" with authority to make payment decisions on behalf of all the investing doctors, he says.
Myers did not wait until architectural plans were complete to choose a builder, as is done on some construction projects. Early on, he tapped a 20-year acquaintance, who had built nursing homes and physicians' offices but not yet any hospitals.
The builder's ability to quote prices for materials, he says, allowed him to keep on top of the project's costs.
"He would say, if we buy our steel three months early, we can get a better price," Myers recalls. "That's the beauty of having someone you absolutely trust."
Myers says he also personally designed the entire project, drawing up floor plans and handing them to the architect, who turned them into architectural renditions.
"I knew how I wanted the rooms, the nurses' station, the administration, to be laid out," he says.
For example, he says he got his idea for inpatient suites in the new wing from the Embassy Suites hotel in Dallas. He mapped out spacious 15-by-40-foot rooms. An enclosed bathroom juts into the middle of the room, dividing the patient's bed from a visitors' living area that has a television, chairs and a couch for overnight stays.
Myers says some designs went through numerous iterations before he got it right.
"I changed the design of the business office eight or 10 times to get it to work," he recalls. He was tweaking plans even after construction started and he was making daily tours of the site.
Walking through the first outlines of the lab, Myers decided to he needed to move the chemical analyzer because "it didn't look like I thought it would," he says. "On paper it had looked a little bigger."
Looking at the nurses' station, "we thought it would be better if it had more drawers," he says. "Also, we dropped the computer station into an inset to provide more room."
And after the ceiling in the records room had been installed, he says he realized that he had forgotten about a state fire code mandating that the ceiling must be a certain distance from the top of the records shelves. He had to raise the ceiling by one foot.
But even professional project managers will own up to making a few such oversights, and Myers says 95% of the project was not changed at all during construction.
Still, developers discourage doctors from taking over their construction projects.
"Physicians shouldn't try to do it themselves," cautions Alan Pierrot, M.D., CEO of FSC Health, a surgical hospital development company in Fresno, Calif. "The people who have done this before bring some very valuable experience to the table.
"The construction of a surgery hospital is a very complicated thing and there are lots of potential problems," he says. "The FSC Health management program has more than 1,000 steps. For example, you need to know when you start hiring people, when you need to order computers."
Pierrot says doctors who have built ambulatory surgery centers figure it will be easy to expand to a surgical hospital, that "a surgery hospital is just a surgery center with beds." But surgery hospitals have different licenses, a different building code, extra services like food and bedding, and three to four times as many employees as ASCs, he says.
"There is a tendency to underestimate what is involved," he says. "There can be some very expensive lessons learned."
For example, Pierrot says one common mistake made by doctors is planning for too much space.
But Myers, as his own project manager, says he got plenty of help from professionals and kept expenses in check by making sure hospital capacity was in line with revenue.
"We had to make sure revenue is there before we add new expenses," he says. That meant that beds and ORs in the original hospital and the new wing opened in stages, as revenue rose.
Myers says the hospital started with about a dozen doctors. Now, he says, 125 physicians use it, and its staff has grown from 30 to 200 employees.
Myers' architectural plans have left room for expansion, should capacity continue to rise. The hospital stands only one story tall, but there is space for a stairway leading to a second floor.
Complex hospital projects usually take years to complete even the initial planning, but the Neurologic & Orthopedic Institute of Chicago, an 85-bed, 10-OR specialty hospital, was planned in just six months, opening its doors in January of this year.
The specialty hospital is a renovation of an acute care hospital that was owned by Advocate Health Care of Oak Brook, Ill., the area's largest healthcare provider.
"It was kind of a frenetic time, but it went unbelievably smoothly," recalls Leonard Cerullo, M.D., medical director and founder of the hospital, which is a partnership between NeuroSource, a neurosciences consultancy based in Chicago, and the Chicago Institute of Neurosurgery and Neuroresearch, a 22-physician practice that Cerullo leads.
Cerullo says his group practice moved into the building in January 2002, when it was still an Advocate hospital.
In June of that year, Advocate announced it was closing the hospital and offered to sell the building to Cerullo's group.
The group agreed to buy the building and began planning a renovation; construction began last October. Advocate's certificate of need with the state was reduced from 400 beds to 85 beds and transferred to the new owners.
Planners, architects and builders met daily with physicians, OR nurses, physical therapists and ICU nurses to go over the designs.
Cerullo says each floor of the eight-story hospital represents a different service.
The operating suites fit easily into the old hospital's ORs. Examination rooms on the new outpatient floor were converted from the old hospital's inpatient rooms and therefore are very large, but it would have cost too much and taken a lot of precious time to gut the floor and start over, he says.
"It was an emotional, intellectual investment by the team," Cerullo says. "They have been together for years and years and then, so to speak, they had an opportunity to design the perfect kitchen."
One major concern, he says, has been installation of a $6.3 million gamma knife, a machine that performs noninvasive surgery on brain tumors and is only the second such device in Chicago.
Because the machine weighs several tons and must have heavy shielding around it to protect against cobalt rays, planners decided to put it in the basement, a floor away from the MRI, CT and other testing equipment at the hospital.
Cerullo says the team pondered such questions as whether physical therapy should be next to the inpatient or the outpatient facility. Ultimately, they chose the outpatient facility, because of its greater volume, he says.
"We got out ideas and they went through multiple iterations," he says. "Things got moved a lot in the planning stages."
Construction on the new specialty hospital is due to be completed in the fall.
"It is very much a work in progress," Cerullo says.