Hospital owners face constant challenges in modernizing their facilities. There is pressure to stay in competition by offering larger and more flexible surgical suites and treatment areas, simplified emergency departments, more single patient rooms, and better infection control. With the current COVID-19 pandemic, it is more important than ever that hospitals provide their communities with the latest advances in healthcare while being flexible enough to respond to unexpected emergencies.
Many of the 6,200 hospitals in the United States are housed in aging buildings that need to be retrofitted to deal with best practices, enhance service lines, and increase energy efficiency, according to the American Hospital Association reports.
Faced with an existing building with restrictions, the leadership may think that a new facility will solve all of its problems. This may be true, but phased regeneration and expansion can provide the same solutions with spreading the cost over time, making this approach easier to integrate into financial budgets.
The big decision
Building an alternate hospital means finding and purchasing available land on a desirable location for construction while the existing facility is occupied and operated. In dense urban areas, it can be difficult to find a suitable space for a new hospital. Moreover, the plan will need approval from various state and federal regulatory entities. This is true whether it is the construction of a new hospital or the renovation of an existing one, but the organizational barriers are usually less complex with the renovation / modernization of an existing facility.
A hospital modernization – which could include an entire building or just a department or system – allows the facility to maximize existing assets by improving functionality, energy performance, and aesthetics. Also, the renovation of existing buildings and campuses is more sustainable and less expensive.
Often the decision to modernize an existing facility or build a new facility depends on what the customer’s drivers are, and on the particular circumstances of that facility. Also, every customer is different, so you have to meet your response to meet their expectations. For example, a current facility may have “good bones” or a healthy superstructure and conform to the current permitted building types for a hospital, but the facility has outdated MEP + FP systems, inadequate care models, or even outdated materials. If the customer does not need to increase capacity to meet the increased volumes, the best solution may be to modernize the facility by upgrading systems, care models and aesthetics to current standards.
If a client is interacting with increasing volumes and needs to expand beyond the capacity of their existing location, whether limited by existing building stock, available land, or zoning restrictions, the new building may better suit its needs. Another factor is that the hospital system looking to increase capacity to meet project volumes will have to file a legal application for a “certificate of need,” which is often met with stiff opposition from competitors. It can be a colossal process, and depending on the hospital system’s confidence in obtaining the CON, the client may choose to upgrade or upgrade an existing facility to increase the level of care.
Assessment of current conditions
If a phased refurbishment is chosen, the next step is a systematic and thorough documentation of the existing structures by the entire design team. This process will provide a deeper understanding of how the organization will use its existing buildings, determine how the facility will operate during construction, and consider what is needed to support future care needs.
The systems assessment of an existing facility entails an in-depth analysis of the mechanical, electrical, plumbing, fire protection and energy efficiency of the engineers. For example, does the central utility station need an upgrade to support the refurbishment? Moreover, hospitals consume large amounts of energy, and many older structures are less efficient and do not meet current energy efficiency standards, which may prompt the need for a more energy efficient approach.
During the discovery phase at the start of the project, it is necessary for the project team to physically enter the building to document the space. Even during COVID-19, when visits are restricted, this process can be feasible by limiting staff; Visit during rest hours, nights and weekends to minimize disruptions; Use safety protocols, such as wearing personal protective clothing. Technology can also help with this process. For example, by using 360-degree image capture technology, the project team can capture a complete image of the facility that can be referenced at any time during the project, reducing the need for additional facility visits and the amount of time the project team spends on the building.
The entire design team, including MEP engineers, architects, laboratories, medical planners, interior and graphic designers, must be involved in building documentation and evaluation to understand the current work of the building as well as compare notes, indicate problems, and identify areas of concern. Existing materials are also evaluated to determine what is old and needs replacement. For projects that involve a construction manager (CM) constructor or CM at risk, it is also helpful to engage that member during the discovery process to provide insight into buildability issues.
It is also essential to understand how the current building operates in the campus context and surrounding areas, such as parking structures and access to the emergency department. Input from the community, which can be gathered through online surveys and brainstorming sessions, provides tremendous value and insight to support this analysis and can help residents understand the benefits of selected options.
Another important step is to conduct a master plan exercise with the client to define current and projected patient volumes and services taking into account the latest evidence-based research on patient care, safety protocols, technology, sustainability, and infrastructure. Here, it may be helpful to conduct a comparative analysis with a small number of peers. For example, a world-class cancer institute might consider establishing other world-class medical facilities, while a community hospital evaluates other hospitals in the area that fulfill the need certification. The process analyzes what the customer has today, compared to their goals and industry best practices. Years later, leaders can return to this report to ask if they are achieving these goals, and provide a clue of what they want to be in and how they know when to get there.
Case study: Children’s Hospital New Orleans
Children’s Hospital of New Orleans is undergoing a 400,000-square-foot expansion and renewal process within a combined 600,000-square-foot inpatient and outpatient facility. The multi-stage retrofit project, which is under construction and expected to be completed by the fall, will take nearly seven years, from master planning to completion, and includes 34 distinct phases. During the upgrade, the hospital will remain fully functional without interruption for daily operations.
EYP Architecture & Engineering was introduced in 2015 and has worked closely with the hospital’s management team – and in collaboration with the community, clinicians and CM at risk – to assess existing structures and develop a comprehensive understanding of the hospital’s operations and aspirations. An early consideration was to construct an entirely new building. A basic group study of concepts and visualization demonstrations was conducted to allow everyone to get an idea of what the new building would look like, as well as a cost estimate based on the square footage and the pros and cons of a new building versus the client’s needs. Ultimately, this process showed that, through modernization, a customer could get almost everything they wanted at half the cost of building a new one.
Going forward, the team decided to use a phased approach to preserve some of the existing buildings to preserve the historical significance while adding new structures to modernize and harmonize the entire campus. EYP has developed graphic tools to guide hospital management and contractors through each of the 34 phases and outline a plan to maintain hospital operation while renovations are being made. One of the first steps was to make space in and around the site to make room for refurbishment and equipment work. To this end, a new car park has been built on the other side of the hospital to move most of the cars off the site. Also, the staff offices on the clinical side of the campus have been integrated into historic structures on the historic site, creating an indoor space. In addition, the laboratory has been moved to create a new master foyer room. After the construction of the new expansion, the intensive care unit and some dining areas have been moved to the new tower while the renovation works of the existing spaces for the new services have commenced.
Throughout the construction process, the team has been careful about what has been shut down to ensure the hospital continues to be fully operational. EYP updates its staging plan every week focusing on user experience and adjusting the schedule in light of emerging changes, such as cost savings, operational efficiencies, program changes, and unforeseen circumstances such as weather events that could have caused delays. There were also instances where the pandemic delayed delivery of equipment, and even labor, because no one was able to come to the site, creating the need for a schedule revision to allow certain spaces to speed up and extend other spaces.
All critical decisions that hospital owners have in mind – how to maintain competitiveness, maintain compliance with updated regulations, and live up to current standards of care and safety – can be met by modernizing an existing hospital. However, making the decision to pursue a renovation rather than a new construction requires a strong partnership between design professionals and contractor, and a deep understanding of the building and the client. All team members should be aware of the plan and work collaboratively to address issues that inevitably arise to achieve a shared vision for a new project.
Matthew Shalifux, FAIA, is a Senior Historic Preservation Engineer and Senior Director at EYP Architecture & Engineering (Washington, DC). It can be reached at [email protected].