Hos­pi­tals de­sign with flex­i­bil­ity

New de­signs em­pha­size adapt­abil­ity in a chang­ing sys­tem

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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 ra­diofre­quency 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 big­box 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 big­box 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.”

BJORG MAGNEA AR­CHI­TEC­TURAL & IN­TE­RIOR PHO­TOG­RA­PHY

KC KRATT PHO­TOG­RA­PHY

De­sign­ers say mod­u­lar grids al­low max­i­mum flex­i­bil­ity in a build­ing, and that in­te­ri­ors don’t have to look like the in­side of a shoe­box, as ev­i­denced by the use of open space in­side Kaleida Health’s Gates Vas­cu­lar In­sti­tute in Buf­falo, N.Y.

ERIK UNGER

The Univer­sity of Chicago’s Cen­ter for Care and Dis­cov­ery has built-in flex­i­bil­ity through mod­u­lar de­signs and two floors of “shell” space.

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