THE CASE FOR INTEGRATED DESIGN-BUILD
Southwest Health Center (SHC), a community hospital in Platteville, Wisconsin, is proving that good things can happen when administrators form a strategic partnership with an integrated planning and design-build firm. SHC faced many challenges when, in 2003, officials tapped Marshall Erdman & Associates (ME&A), a national firm headquartered in Madison, Wisconsin, to help plan, design, and execute their bold new facility.
The old building was out of date and out of space. It wasn't providing the necessary services for patients, let alone accommodating staff. Even more disconcerting, there was no room for growth. Involvement of a design-build firm seemed essential to the solution.
Technically, the term design-build refers to a system in which a single entity provides planning, architectural, engineering, and construction services under a lone contract. However, that definition doesn't encompass the many advantages of design-build, as exemplified at SHC. Three years and just under $27 million later—a month ahead of schedule and under budget—the new and vastly improved SHC is a testament to the value of having one company oversee everything in a new project, from conception to handover.
“We had worked with different architects and builders in the past,” says Anne Klawiter, SHC's president and CEO. “But when we used design-build, the process just seemed to go so much smoother.”
A Growing Trend
Design-build has gained an increasing share of the construction market and a rapidly expanding amount of healthcare facility work. According to Richard Belle, Vice-President of Public Affairs/Information at the Design Build Institute of America (DBIA), the design-build model now represents 40% of all nonresidential construction work. What makes it a superior delivery model? Research conducted by Victor Sanvido and Mark Konchar and first published in the April 1998 issue of Design-Build indicates that the design-build delivery model outperforms design-bid-build (DBB) and construction-manager-at-risk (CM®R) approaches in all areas: costs, change orders, schedules, and quality.
The study, which was done through Penn State University with lead sponsorship from the Construction Industry Institute (CII), used actual construction data from 351 projects and found that the design-build unit cost was at least 4.5% less than CM@R and 6% less than DBB; the study also demonstrated that design-build had 5.2% less cost growth (change orders) than DBB and 12.6% less than CM@R. Design-build was also found to cut delivery times, including design, by 23% over CM@R and by 33% over DBB. On a scale of 1-10, design-build scored close to 8 in terms of operation and maintenance quality, while DBB and CM@R both scored below 7.
“Our clients know when they work with us that we all are on the same team and have the same motivation to get the facility built,” says Frank Feit, construction project manager at ME&A. “We each have different expertise, but none of us wins until the client gets the building. Our product isn't just planning. It isn't just designing. It isn't just construction. The benefit is that it's all of that.”
Putting Form to the Vision
In spring 2005, SHC opened the doors on a three-story, 102,000-square-foot hospital and a two-story, 36,000-square-foot adjoining multiple-specialty medical office building. Built on a 30-acre site with easy access to the freeway, the hospital houses 25 single-occupancy patient rooms, with flexibility to expand without changing the original footprint. Shell and soft space can be manipulated to accommodate new technologies, such as using filing space for other purposes when SHC moves to electronic health records.
SHC's clean, geometric lines are reminiscent of buildings fashioned by famed Wisconsin “favorite son,” architect Frank Lloyd Wright. Like Wright, ME&A's designers wanted a structure that not only fit the site, but seemed to grow out of it. It also had to reflect the client's priorities: functionality, flexibility, efficiency, and a soothing environment. “We really listened to the client and the community,” says John Ford, project designer. “We always want to provide a nice-looking facility, but, ultimately, every building looks unique because it's based on the goals and vision of the owners.”
Part of the Southwest Health Center entrance, this crossroad is marked by backlit, overhead glass to create a focal point and reinforce a sense of arrival for the patient. The design team at Marshall Erdman & Associates took cues from the community's long mining heritage, incorporating slate and wood beams to reflect a sense of pride in the area's history.
Off the MOB's main entrance, this dramatic stairwell channel is an efficient wayfinding device that conserves square footage, maximizes daylighting, and glows like a beacon for patients approaching the hospital at night.
From its rough stone base to its smooth sculptured top, the exterior evolves through texture and hue changes, reflecting the area's indigenous limestone. Inside, wood beams, square columns, and slate tiles cap the design by alluding to the area's rich mining history, a theme echoed in the trickling of a water feature.
The designers instituted features to reinforce SHC's new philosophy as a welcoming, efficient place, beyond aesthetics. They created prominent and distinctive main entrances to both the hospital (figure 1) and the MOB (figure 2) to ease wayfinding. Once through the door, visitors are greeted and escorted. “We were very cognizant that it's not always pleasant to be here,” says Klawiter. “So we tried to take some of the anxiety out of the visit.”
Marshall Erdman & Associates sited the facility to take advantage of the soothing vistas surrounding the hospital. Oversize windows in patient rooms allow ample daylighting and a calming environment, furthered by attractive but functional design that conceals medical equipment.
The designers also facilitated both the hospital's dual use and future needs. For instance, the ambulance garage has decontamination showers for larger agricultural or industrial accidents. Core diagnostic and testing services are located on exterior walls so they can be expanded easily.
The biggest interior feature actually comes from outside. Walking paths connect every corner of the campus to a healing garden. With windows lining the perimeter (figure 3), the workspace has natural light in the majority of areas. “You'll find very few walls at the ends of our corridors,” says Klawiter. “We made sure that there was a glass wall or window. I think light makes a huge difference for staff. It certainly is more welcoming for patients.”
Accelerating the Schedule for Savings
Because its services are integrated, ME&A was able to pass along significant savings to SHC at numerous junctures in the project's life cycle. For one thing, the firm fast-tracked the construction schedule, breaking ground in August 2003 and laying the foundation early to take advantage of a very dry summer. The site had unusually high moisture content and would have required expensive soil replacement if the team hadn't been able to move the project forward—even though it was still just in the early stages of design development. Similarly, by working closely with the designers, construction managers shifted their estimates to actual subcontractor proposals, which allowed for firmer budgets and cost controls almost from the start. The architects could weigh the impact of any changes using reliable real-time cost and scheduling information submitted by construction pros.
An integrated design-build firm also greatly reduces change orders. There were no change orders generated by ME&A, and SHC's change orders totaled less than half of 1%. That meant big savings and assurance of quality work backed by accountability. “In a traditional environment, general contractors bid a set of plans based strictly on what's in them,” says Feit. “They're not accountable for errors and omissions, but we hold ourselves accountable.”
Among side benefits, the team was able to channel $6 million in subcontractor work into the local economy. It also raised SHC's environmental profile by recycling raw metals, turning wood into mulch, and crushing drywall into gypsum and sprinkling it on local fields.
Finally, there was no finger pointing, since the whole team took responsibility for the project as a group. With one phone call, there were answers to any of Klawiter's concerns. “I've worked with other types of firms, and there's always the question, ‘Who's responsible?’” she says. “But there was none of that here. I only had one place to go with my questions.”
Reaping the Rewards
SHC not only has increased its market share, but it also has far exceeded financial projections for its services and programs. The design-build team helped the hospital set realistic business goals and then outperform them. Within six months, many areas in the hospital measured double-digit increases in usage and exceeded projections. Specifically, emergency room visits increased by 13%, inpatient surgeries by 10%, outpatient surgeries by 15%, and specialty clinic visits by 16%. In addition, usage rose in key diagnostic areas: stress tests went up by 44%, MRIs by 24%, and laboratory use by 15%. By designing for efficiency and maximized patient throughput, the design-build team enabled SHC to handle significantly increased volumes.
Meanwhile, the aesthetic properties of the design communicated that SHC was delivering top-quality care, which led to increased referrals and capture of a larger market share. SHC is not only attracting patients from its five-county region, but from as far away as Dubuque, Iowa. In addition to primary care, SHC is now able to expand secondary care services, such as cardiology, ophthalmology, otolaryngology, neurology, and urology. While some of these specialists were already practicing in Platteville, the facility is now attracting physicians and staff from a much broader area. “Administrators are usually trying to find providers for their facilities,” says Klawiter. “We'll always be looking—but it's nice to have them want to come to us, too.”
An integrated design-build firm proved to be the perfect model for SHC. Because of the strategic partnership, officials now have a hospital positioned for the future but poised to take care of patients and all their needs now. By integrating many disciplines and services, the design-build team guided its client through a complex process, overcame construction challenges, saved the client money, and finished ahead of schedule and well within budget. Most importantly, SHC has a hospital that's both efficient and inspiring. As Klawiter sums up, “We're extremely pleased.” HD