Building a nimble hospital

Though it might seem counterintuitive, healthcare design experts are saying standardization is the key to flexibility—and the ability to be flexible can mean the difference between going ahead with a construction project or going through another round of costly planning and trying to predict where healthcare is headed.

While it's clear that healthcare reform is going forward, it still remains uncertain exactly how services will be provided and where they will be delivered. Experts say that flexible designs are a must, because they allow organizations to move ahead without constant fear of taking a wrong step that will hinder strategic initiatives for years to come.

In describing this state of flux, Chip Cogswell, national healthcare director for Turner Construction Co., says healthcare organizations are finding themselves with “one foot on the dock and one foot on the boat.”

Andrew Quirk, senior vice president and national director of Skanska USA's Healthcare Center of Excellence, agrees with Cogswell's assessment. But he says the remaining uncertainty is not whether reform will be rolled back but what will it look like going forward.

He sees standardization of hospital spaces as the end result—but not rigid standardization. Instead, he says creating identical spaces can facilitate the ability to quickly adapt a particular space as needs change.

“I think you're going to see a lot more of that—the standardization of design,” Quirk says. “Not only to be able to change the type of care they're delivering, but who they're delivering it to.” Standardization and flexibility “go hand in hand,” he says.

While healthcare reform is “pushing to the outpatient model,” plenty of questions remain about which types of services will be provided where and which services might draw higher reimbursement rates, Quirk says.

“You have to have an eye on the future,” he says. “The ability to go from one type of procedure to another is the flexibility that will be important to hospitals.”

Quirk says standardized room layouts are the key to incorporating flexibility into two projects: the design of Louisiana State University's new $1.2 billion University Medical Center in New Orleans ($760 million of that total is allocated to construction), and the $450 million renovation of 305-bed Stamford (Conn.) Hospital.

Quirk says he expects to see fewer and fewer hospital projects with such high price tags, noting that $200 million is becoming the “new large.”

But some megaprojects are still in progress, including the new Parkland Memorial Hospital campus in Dallas, which will have 862 beds and cost more than $1.27 billion when it's completed in the winter of 2014.

“The facility will be adaptable,” according to the hospital's website. Lou Saksen, Parkland's senior vice president of new hospital construction, says standardization (along with creative use of shell space) will drive that adaptability.

“The design of the hospital facilitates adapting to changes in patient mix through standardization,” Saksen says. “All patient rooms in the towers are basically identical left-handed—patient's head to the left as you enter the room—on all floors and for all services.”

Intensive-care, acute-care and postpartum rooms will all be the same size, he says. The three patient bed zones—for trauma, medical/surgical and women and infants' specialty health—will be interconnected. Using that approach, growth in one service area can expand into an adjacent area as needed because of changing patient demographics, Saksen says. Anticipating a continuing shift in diagnostic imaging from CT to MRI, Saksen says the rooms housing both types of equipment will be of the same size, so the switch can occur with ease.

The neonatal intensive-care unit rooms on the new hospital's fourth floor are all of standard size and divided into eight 12-room pods, allowing expansion to a full occupancy of 96 beds and easy contraction as demand changes, Saksen says.

Many empty or “shell” spaces will be kept open throughout the hospital to accommodate future needs, including three operating rooms “that will await future surgical trends and patient volumes,” he says, concluding that “we believe Parkland's new inpatient facility will be poised to adapt quickly and efficiently to the changing patient landscape.”

The same claim is being made about the University of Chicago's new $700 million, 1.2 million-square-foot Center for Care and Discovery scheduled to open Feb. 23 with space for 240 private patient rooms and 52 intensive-care beds.

Designed by Rafael Vinoly Architects of New York and Cannon Design of Grand Island, N.Y., the massive structure features roughly 100,000 square feet in 510-foot-by-180-foot rectangles on each of its 10 floors. And those floors have been divided into 85 “modular cubes,” or bays, measuring 31.5 feet across and 18 feet high. Two stories of shell space are being reserved for future uses. (There is also a basement and a “mechanical penthouse” on the 11th floor.)

The building's flexibility-enhancing modular grid has already been put to the test with a late-in-the-game redesign of its operating and procedure rooms on the fifth and sixth floors that occurred long after ground was broken in 2009.

“Both floors are very similar,” says Elizabeth Rack, Cannon's medical planning principal for the project. “The thought was that, over time, the border between surgery and interventional procedures would become less so and they would intertwine. But during construction, this already happened,” requiring more space to be converted to cardiology.

While work will continue in some areas of the facility past the Feb. 23 opening, the universal grid system will allow this to happen with minimal disruption to adjacent spaces, Rack says. “It was really quite pleasant to see how easily it could adapt,” she adds.

The facility has nine advanced imaging and procedure suites plus 21 operating rooms with room to add seven more.

(In another demonstration of flexibility, the University of Chicago went outside the healthcare industry to design the new facility's inventory-control system. It tapped Jon Stegner, a former supply-chain executive with manufacturers Delphi, John Deere and Honda, to design an automated inventory system where supplies are automatically reordered when they are running low and equipment is tracked with radio-frequency identification tags.)

Chan-li Lin, a partner with Rafael Vinoly and project director for the Center for Care and Discovery, says the building has “extreme flexibility” as each floor carries an identical footprint “without any floor purposely built for any particular function, ” creating “a sense of possibility.”

“The way in which healthcare providers do their work changes every day,” he says. “The only things that remain constant are the changes.”

He says one goal was to maximize the value of the site. So the final product, he says, “is not a luxurious building, not a fluffy building.” But—despite its rectangular shape—he says it's not just a “big box” either.

One way this was achieved was moving the main lobby from the first floor to the seventh floor, creating a “sky lobby” as the building's main public space. Overlooking the shorter buildings on the university's campus, it provides views of downtown Chicago and Lake Michigan.

“I think the Center for Care and Discovery is a good model for other hospitals' new facilities—particularly in an urban setting,” he says.

M. Kent Turner, president of Cannon Design North America, says that, ultimately, every hospital being built—with rare exceptions—will be based on some type of grid system. But so far few are designed with “a lot of rigor and attention” to what the grid can support and be used for, he says.

He says Cannon has developed 40 grid templates that can be adapted for various building uses. Writing in Inside ASHE, the journal of the American Society for Healthcare Engineering of the American Hospital Association, Turner disagrees with the notion that “every healthcare facility designed using the universal grid planning module will look like a variation of a big-box warehouse.”

Although these facilities will be based on modular designs, Turner tells Modern Healthcare that hospitals will still have “the ability to carve into the interior grid and to sculpt the exterior.”

He cites Indiana University Health's Neurosciences Center of Excellence in Indianapolis and the Kaleida Health System Gates Vascular Institute/SUNY Buffalo Clinical Translational Research Center as two other examples where creative carving of the interior grid avoided a big-box environment.

Turner says the modular layout allows for construction to begin even as the design is in flux. For a recent project in the St. Louis area, he says that capability “saved a massive amount of money—and that was just a function of time.”

Turner notes, however, that some hospital administrators balk at the 18-foot floor-to-ceiling heights included in the modules. He says these can be adjusted and, while 18 feet was the standard in the Chicago facility, some floors have different heights.

The important aspect is the “striating” of plumbing, electrical conduit, fire suppression and other piping systems in the ceilings. This method allows the piping units to be assembled off site (and not by workers standing on tall ladders), eliminates space conflicts and reduces construction time—which all decrease cost.

Rack concludes that all this planning and design has made the new University of Chicago facility “really much like a machine—we hope like an attractive machine.”