Master Planning a Rural Health System for the Big Leagues
When the Bassett Healthcare System, based in Coopers-town, New York (yes, that Cooperstown), asked us to participate in the RFP for a master plan, we knew that they had been reviewing their organizational strategy for some time. Bassett's centerpiece is a 200-bed hospital and closed-group practice employing some 2,500 people in a town of a couple thousand that rapidly expands to 30,000 or more during the baseball season. But it also has 23 ambulatory care facilities for diagnosis and/or treatment scattered over a nine-county area. Bassett's goals were to get the right services delivered to the right areas, to buttress this far-flung network and be equipped to offer high-tech cardiology surgical procedures in order to draw patients from such urban centers as Albany and Syracuse.
One of the system's strategies was to develop a comprehensive heart service line, including interventional services. The reason that the concept of Bassett's performing heart surgery in a rural community was not a hopeless fantasy was that Bassett is a teaching organization affiliated with the Columbia-Presbyterian Medical Center in New York City. Many of Bassett's 200+ full-time, salaried medical staff have teaching appointments at that institution, and they and others also conduct medical research at this rural campus.
To maintain its attractiveness to both physicians and patients, though, Bassett knew it had to plan its way into the 21st century. Aside from reinforcing its strengths in its satellite facilities—for example, cardiology was particularly strong in its northern counties and cancer care in its western counties—Bassett had to significantly upgrade its 100-year-old inpatient hospital, the newest portions of which had been constructed in 1969.
Because of the apparent scope of the project, we proposed going beyond the typical six-month master plan process and marrying Bassett's strategic planning to its facility planning in a study that ultimately took about a year. The view was expanded to a system-wide master plan, looking at facility delivery locations for all service lines throughout Bassett's nine-county service region.
Our firm gets involved in this type of planning quite frequently. We're architects and designers, but we subcontract with strategic planners, real estate advisers, and other parties with expertise in organizational development. Our overall philosophy is to have the strategy precede and drive the facility planning, not to have the facilities drive the strategy.
In this case, we determined that Bassett's regional facilities were, for the most part, in the right localities and had adequate capacity to achieve the organization's strategic objectives. We also saw that most of Bassett's financial investment during the 1990s had gone to developing this network, and that the old hospital had been maintained in more or less patchwork fashion for more than 30 years. Basically, the hospital consisted almost exclusively of semiprivate patient rooms and surgical facilities lacking sufficient infrastructure to support contemporary procedures. We determined that upgrading the hospital and the network would be a $100 million project.
Bassett didn't have $100 million to invest up front. The question then became the extent and timetable of the new investments that would be needed.
As with all older hospitals, Bassett confronted the basic question of whether to renovate or build new. In this case we developed alternatives to consider: to both renovate and build new, or to construct a significant addition to the existing facility and use its oldest pieces to house offices and administration. Bassett chose the latter as the most financially feasible.
Then came the decision on how the master plan would be structured. With the project's $100 million price tag, the planners decided to phase it in, beginning with the high-revenue modalities, such as cardiovascular surgery, and expanding diagnostic and invasive cardiology services. The revenues from these programs and others will be used to fuel the next phases. We gave Bassett “pull points” along the way—that is, after completing a particular phase, if Bassett decided that it could not continue with the project, work could stop and Bassett would still have a functioning hospital.
As it worked out, specifically, the first phase was vertical expansion of the patient tower, adding a fifth floor to allow for one of the lower floors to be vacated for expanded surgical space. The added surgical space—12 operating rooms, including two dedicated to open heart surgery, along with upgraded radiology and intensive care spaces—would be the financial enabler for renovating the remaining patient floors. In this case, “renovate” meant to increase the size of patient rooms, create more private rooms, and provide family amenity spaces.
A major portion of this project—56% of the construction budget, to be exact—will be devoted to upgrading the engineering infrastructure. This level of expenditure is not at all unusual for old hospitals, many of which were constructed during the early Hill-Burton years in the 1950s and 1960s. Bassett's hospital had HVAC, plumbing, and electrical systems dating back to 1969. Moreover, it had virtually no seismic resistance, a consideration in this area, where earthquakes do occur. As a result, we've redone the entire core of the building with new mechanicals, electrical, plumbing, and elevators, as well as a new structural system.
Total replacement of engineering systems is occasionally required in old hospitals—although, admittedly, it can be frustrating for clients to see so much of the construction budget going into things no one will ever see. Sometimes, too, clients’ expectations can be completely changed by the master planning process. Clients will think they have a building project at hand, only to find, in fact, that the issues have nothing to do with new facilities. It might be that all they need is to reorganize somewhat to use their existing space more efficiently. At Bassett, for example, the client assumed that an apparently overcrowded 156,000-square-foot ambulatory care clinic it operates in Cooperstown would have to be expanded. The master planning team did a capacity assessment of the clinic and found that, while it was indeed filled to overflowing on Wednesdays, utilization was well below desired levels on Friday afternoons.
That, too, describes an aspect of hospital master planning. It doesn't always mean more and bigger buildings, but finding ways to use what exists more efficiently. HD