AIA AAH: High Stakes Of Healthcare Planning
“The future isn’t what it used to be.”—Paul Valery
This great quote, often misattributed to Yogi Berra, has been an icebreaker in my presentations for more than 20 years. As medical planners, and therefore futurists, our world is all about making important decisions about things that haven’t happened yet based partly on past evidence, what we know will change, and some educated guesses on what we think will change.
With hospital construction taking upwards of 10 years from planning and design to construction and occupancy, we’re often proven wrong even before the first patient arrives. This is high-stakes betting impacting billions of dollars and ultimately millions of lives. Luckily, we now have a catchy buzzword for this line of work: Future proofing.
One of the past truths about healthcare design was that hospital buildings have a lifespan of about 50 years, meaning that after a certain amount of time, the cost of ongoing renovation to a facility equals or surpasses the cost of a full replacement building. That’s certainly been the case at Stanford Health Care, (Palo Alto, Calif.). When the Stanford Medical Center moved from San Francisco to Palo Alto in 1958, it was state-of-the-art. Unfortunately, the facility didn’t include such things as seismic safety, accessibility, air-conditioning, IT infrastructure, and all private rooms—things that are now expected or required. Worse yet, our surgical and imaging services are located in a 25-year-old addition that’s already met the definition of lifespan.
With the new hospital nearing completion, my design team proudly states that advances in technology and construction will enable the building to have a lifespan of 100 years! And although I already have a growing list of WTF (Work to Follow) change requests, there are several future proofing things that I think we got right:
• Structural support: The decision to use a base isolation structural system versus a traditional moment frame or shear wall system may have had an initial up-front cost, but here in earthquake country, it was well worth it. The base isolation system places isolators (like shock absorbers) under each foundation column, so the entire building moves in unison during a seismic event. It provides a simple, lighter structural grid with minimal cross-bracing, which makes initial and future planning much simpler. In our design, it also allowed for expansive patient room windows, highlighting our spectacular views of the university campus and Silicon Valley.
• Universal rooms: We chose to use the same unit and room modules for critical care and acute care, which has allowed us to adjust both the ratio of critical care to acute care rooms and the ratio of nursing staff to patient (acuity adaptable unit nursing). The units were purposefully not customized by service or location, allowing for operational changes even before opening day with no impact on construction schedules. This is critically important for institutions like ours that are growing quickly and serving a complex patient mix.
Additionally, I’m glad the hard-fought battle over private rooms with family rooming space appears to be over. The progression from wards to semi-private rooms to private rooms has come to its logical conclusion and we can’t go to less than that. Add to that the fact that we maximized the size of our core support areas by choosing a square-unit geometry rather than our previous triangle formats, and I’m confident that these units will be good for the life of the building.
• Intervention platform: Personally, I’m most proud of the intervention platform concept we’ve created, which combines surgery, cardiac catheterization, angiography, and other procedural spaces on one floor under one integrated support umbrella. For example, our cardiac operating rooms share the same patient corridor and are the same size as cardiac catheterization labs. As more heart procedures trend toward minimally invasive catheter-based technologies, we can simply convert ORs to Cath labs with no change to support services. With 31 rooms, including four hybrid ORs and 70 prep/recovery bays, it’s a very big idea whose time has come. We purposefully delayed approval of the plans of this area until the last possible moment to allow us to integrate the most current technology and completely re-evaluate the programmed uses, and it worked beautifully. Planning for change simplified change, now and in the future.
While I would prefer to end on a positive note, there are a few things I know we clearly didn’t anticipate, and it will be up to the next generation of planners, architects, and engineers to deal with them. Technology may not keep getting bigger (thankfully), but it’s getting better, faster, and more powerful. The next generation of imaging equipment will be ten times faster, have a hundred times better definition, and (yikes) require power and cooling loads of similar impressive numbers.
We anticipated some additional capacity, just not the magnitude of it. Will our beautiful roof gardens be replaced by additional air handling units? Will clinical space be lost to additional shafts? HVAC may be up to 40 percent of the cost of current construction, but its drain on future costs of renovation may be even higher. And have I mentioned emergency power and diesel-powered back-up generators?
I have no doubt MEP issues will be the ultimate limitation on building lifespan unless significant advances in technologies come to the rescue. I’m an optimist by nature, but I have little faith that I understand exactly what the future holds. It’s hard to be a visionary when the future isn’t what it used to be.
Dr. George Ruhl Tingwald, AIA, is director of medical planning at Stanford Health Care (Palo Alto, Calif.) and is a member of the AIA Academy of Architecture for Health. He can be reached at firstname.lastname@example.org.