Deciding whether to renovate an existing facility or build a new facility from the ground up is not for the faint of heart. Fortunately, there are a few key elements in the process that can assist you in clarifying the key decision points. Typically, these come up as the organization creates a master plan or conducts a feasibility study. The first step in considering either renovation or new construction is to gather assumptions. Starting here rather than a “goal-setting” meeting helps reveal the real goals of the stakeholders and allows assumptions to be tested. In the end, challenging assumptions allows for more creative problem solving and solutions to emerge as you weigh the options to renovate or build new.

The next step is to define goals with clarity of purpose. Project goals are not clichés, but rather have specific desired outcomes—a difference shown in the table. Clearly defining goals helps to tie the project to the operational pathway. It is also important to prioritize goals and to specifically answer the question, “Our definition of success will be fill in the blank.”

Clichés versus Definable Project Goals

Clichés

Definable goals

We want to make the patient care space warm and inviting.

Patient satisfaction with the environment of care will increase 3 to 5 points.

New space to increase volume/admissions.

Increase exam/treatment rooms by 25% to reduce time to appointment delay to two weeks for routine visit.

More support space for parents.

Add 10 parent rooms, doubling existing rooms.

Decision: Renovate

Over the last four years, Massachusetts General Hospital (MGH) has completed more than $30 million in renovation projects involving several buildings on its main hospital campus and adjacent leased spaces located on a tight urban site in Boston. The master planning process started in 1998 and generated a series of major projects, resulting in the opening of the new Yawkey Ambulatory Care Center building in October 2004. This new construction, however, provided the opportunity for MGH to reorganize across a range of programs, from inpatient beds to primary care. Ambulatory practices moved out of the core into the new building, to neighboring leased space, and to new satellite locations miles away. Prior reorganizations had already moved nondirect clinical services—such as billing, public affairs, and IT—off campus.

Existing conditions posed multiple problems during planning and design, including minimal or no swing space available for temporary relocations; the need to maintain daily delivery of care; low to zero tolerance for any projects that might limit capacity even temporarily; and infrastructure obstacles such as small structural bays, low floor-to-floor height, and stressed ceiling plenums. Advance planning for phased implementation of the design had to be orchestrated with daily clinical and facility operations during construction. Multiple shutdowns of engineering systems had to be coordinated not only within the project boundaries, but also with adjoining departments.

The team that managed these multiple “backfill” renovation projects planned more than 300,000 building gross square feet. This core team developed options for the space assignments and renovation scenarios. These were presented to MGH leadership, who in turn assessed the needed capital planning direction in line with their strategic planning. Subsequent development by the core team and assessment by MGH leadership converged on the final plan. This was an iterative process, but once the decisions were made, the projects moved forward with what some might describe as a relentless pace.

The backfill renovation project strategy was to triage the projects into categories by building or subspecialty, such as intensive care units, and have the best experts paired as teams to address their areas of specialty. Allowing each team to identify its own challenges, from the physical space to the budget constraints and the personalities involved, helped maintain as transparent a process as possible.

Each project team was allocated to a “building” or specialty rather than a programmatic approach. Each team included people from MGH and other groups, such as architects, engineers, and construction superintendents, who had institutional history and were able to offer site and/or building-specific answers to problems while dealing with different occupants of the space. Empowering key people to make decisions from the user perspective at those meetings greatly facilitated the workflow and schedule. Positive, optimistic attitudes and a sense of humor sustained the groups as the projects progressed through the inevitable changes. Thus, the same team of architects, engineers, and contractors worked with the same MGH planning team on the neonatal and pediatric ICUs, while another team worked on an old building being renovated for administrative space.

So, were these renovations successful? From relocating the dermatology suite to an off-core campus site, to a renovated home for a large primary care practice, the consistent answer from the clinicians and managers involved has been unequivocally yes.

Decision: Build new

One could almost say that age discrimination exists when it comes to evaluating whether or not to renovate an existing healthcare facility or build a new one. Today, hospitals are renovating space that can be as young as 10 years old or less. But even that might not be fast enough—services and programs grow, as always, along with patient demand, new diagnostics, and new equipment. In healthcare, therefore, there are many reasons for new construction, including lack of existing real estate to renovate for expansion, introduction of new service lines needing new space, or correction of building deficiencies because of age, antiquated systems, or capacity issues.

Correcting these deficiencies includes integrating new technology such as PET/CT and ceiling booms, installing new mechanical, electrical, IT, and plumbing systems to lower energy costs, and increasing the size of the facility to accommodate more patients and/or specialties. A brand new facility can also be a catalyst to motivate capital fundraising efforts. Furthermore, a new facility is more appealing to potential recruits and employees and offers marketing/rebranding opportunities for the organization in the community.

One such example is the story of the comprehensive construction undertakings at the Pennsylvania State University Hershey Medical Center. Penn State completed a master plan for the Clinical Quadrangle of its Hershey Medical Center Campus in 2005. The area of study included a Cancer Institute, a Children's Hospital, and a hospital main lobby totaling more than 400,000 square feet. The program also includes a new 2,000-car parking garage and a significant redesign of the main approach to the hospital. The Cancer Institute is currently under construction, while the Children's Hospital is in design. The critical mass represented by this new construction will shift the center of gravity of the entire hospital complex and will redefine the access, circulation, and identity of the reconfigured Hershey Medical Center.

The new Cancer Institute is an experiment in full translational medicine, as clinical, research, and educational functions are coalesced to promote collaboration, exchange of intelligence, and seminal discoveries to cure cancer. Translational medicine is also known as “bench to bedside.” Clinical functions are located on the lower three floors and research labs on the top two levels. Researchers and clinicians share offices on the top two floors, with ancillary support spaces located to encourage spontaneous encounters across groups.

The new four-level Children's Hospital will accommodate patient beds for medical/surgery, intensive/intermediate care, and oncology. Acuity-adaptable patient rooms is a given design parameter. It will also include an entire floor devoted to surgical procedures, in addition to amenity programs on the first floor. Capacity for vertical expansion of three floors will be built into the infrastructural systems.

Renovation of the existing Medical Center to house these two major service lines could not be accommodated due to the immediate lack of available real estate and appropriate infrastructure, in particular workable floor-to-floor height. For the Cancer Institute, the goal to attain National Cancer Institute designation required integrating a significant research component with the clinical practice. Moreover, expansion of current programs and inclusion of new programs simply could not be accommodated within the confines of the existing facility.

There were other crucial considerations in the decision to build new. For both the Cancer Institute and the Children's Hospital, the desire to have branded identities as Centers of Excellence posed challenges as hospitals within a hospital, whereas constructing them as new, stand-alone buildings connected to the main hospital seemed the more viable alternative. Also, in terms of recruitment, to work in a brand new facility has always been a major draw, especially with clinical and research staff. Finally, fund raising initiatives are always more robust when potential donors can be shown images of new facilities.

For Hershey Medical Center, driven by the major expansion of two critical clinical programs, new construction of the Cancer Institute and the Children's Hospital brought opportunities to make improvements to the existing hospital—for example, expanding critically needed adult beds, as well as building support services, such as pharmacy, central sterile processing, food service, and materials management.

Conclusions

From small projects to strategic master plans, healthcare facilities of all shapes and sizes can use similar processes to reach an informed decision regarding building new or renovating to enhance the future of their facilities. HD

Paula Buick, RN is an associate with the Boston-based architectural design firm Payette. As Clinical Care Planner, she combines strong project management experience with a unique perspective of clinical operations, having been an ICU nurse and Senior Project Manager at Massachusetts General Hospital (MGH) Partners Healthcare Inc, for many years.

For more information on the firm and its healthcare projects, please visit http://www.payette.com. To comment on this article, visit http://www.healthcaredesignmagazine.com.

Sidebar

Lessons Learned

The following are keys in deciding and implementing a renovation-versus-building-new decision:

  • With a good team, even the most critical acute spaces in healthcare can be renovated successfully.

  • Don't overestimate upheaval–document it.

  • Spend time outlining project phasing.

  • Remember, it's the physiology of the building, not the bones, where you spend your money.

  • Time and escalation are the enemy: Weigh against the two approaches.

  • Expose assumptions—and challenge them.

  • Don't “discriminate on age”—quantify the reasons for your decisions.

  • Avoid overestimating renovation and underestimating new construction costs.

  • Include operational planning/costs in your calculations.

  • Include early—and then honor the views of—your engineers.

  • Have energy costs data in hand.