The cost of innovation
Based on “Can Planning Innovations Coexist With Today's Construction Cost Crisis? Case Study: Palomar Medical Center West”, a presentation at HEALTHCARE DESIGN.06, November 7, 2006, in Chicago by Stephen Yundt, AIA, ACHA, Principal, CO Architects, Los Angeles; Frances Moore, AIA, LEED AP, Senior Associate, CO Architects, Los Angeles; Bill Rostenberg, FAIA, FACHA, Principal, Anshen+Allen, San Francisco; and Joe Hook, LEED AP, Vice-President, Estimating, Rudolph and Sletten, San Diego.
Design matters. Healthcare architects know that hospitals must be built as environments that foster healing and quality of life for their staffs, patients, and visitors. In today's uncertain construction climate, creating hospitals that offer better, safer, and more technologically advanced healthcare can be costly. So how do we preserve design integrity and promote progressive healthcare while responsibly managing our clients' budgets?
In designing the Palomar Medical Center West in Escondido, California, Anshen+Allen Architects for Palomar Pomerado Health (an association of CO Architects [Los Angeles] and Anshen+Allen Architects [San Francisco]), provided flexibility. By including such features as acuity-adaptable rooms, universal operating rooms, and the progressive Integrated Interventional Platform, Palomar Medical Center West will be able to more easily adapt as new advanced technologies and clinical practices emerge. While it may seem that innovative healthcare design is more costly, we'll use the example of this project to explore how the long-term clinical and financial benefits far outweigh the initial costs and show how hospitals and healthcare architects cannot afford not to build for flexibility and innovative care models.
History and Project Drivers
Palomar Pomerado Health (PPH) District is in North San Diego County and comprises two hospitals—Palomar Medical Center (Escondido) and Pomerado Hospital (Poway), as well as two skilled nursing facilities, five outpatient health centers, and an ambulatory surgery center. A confluence of factors—including an increasing population and demand in the area, site constraints, aging infrastructure of the existing facilities—and a need to update and improve its market position drove PPH to pursue a district-wide upgrade/replacement project.
Throughout 2003 and 2004, PPH developed a facilities master plan and embarked on a comprehensive research project to educate itself about the current trends in healthcare design and delivery—including the creation of internal “champion teams” to explore innovative care delivery, tour facilities nationwide, have discussions with experts, and sponsor a “Hospital of the Future” conference. After funding was secured from a General Obligation Bond, PPH was ready to rebuild its healthcare district. While this district includes only two hospitals, the project has three components: to revamp Pomerado Hospital, to upgrade the existing Palomar Medical Center (Palomar Medical Center East), and to design a new campus a few miles away to be designated as Palomar Medical Center West (Figure 1).
Site plan (A) and model (B) of the Palomar Medical Center West campus. © Anshen+Allen Architects for Palomar Pomerdo Health.
The current healthcare environment is replete with patients who are discriminating about their healthcare facilities and providers. San Diego County is a highly competitive market that is home to several high-profile and exceptional hospitals. In addition to keeping pace with the competition, hospitals must cater to a new generation of patients—namely the baby boomers—who have higher standards of healthcare provision1. They also expect more technologically advanced healthcare that allows them faster healing times and an earlier return to their day-to-day existence2. PPH capitalized on this opportunity to revamp its brand image by creating a new hospital—one that would more adeptly reflect PPH's vision for healthcare while becoming emblematic of the future of healthcare delivery.
Visionary design must start from the top, and PPH CEO Michael H. Covert and his colleagues are dedicated supporters of The Center for Health Design and its goals to breed a new standard of healthcare delivery from the architecture and design of healthcare facilities. In 2000, The Center created the Pebble Project, a research initiative that focuses on the real effects of design in the quality of healthcare delivery. In early 2004, PPH became a Pebble Project Partner and began to pursue a design team that was just as committed and motivated to creating a new level of innovation in healthcare. Anshen+Allen Architects for Palomar Pomerado Health has been actively involved with The Center's initiatives since its inception.
What defines “innovative” healthcare? Anshen+Allen Architects for Palomar Pomerado Health focused on three design components:
Sustainable and green elements
Evidence-based design features
Going Green. Sustainability is our present and future responsibility; it preserves our earth's resources, provides safer healing environments, and can minimize water and energy costs. Palomar Medical Center West will feature green roofs (they reduce storm water runoff, protect the roof, and offer respite and a connection to nature), skylights and lightwells (these filter light into dark interiors, promote wayfinding, and improve patient/staff dispositions3) and sunscreens (which minimize AC costs and improve patient/staff comfort). Additionally, the campus will feature daylight controls and occupancy sensors to minimize wasteful electricity usage, a cooling tower for waste water to irrigate the campus's landscape, and low-flow fixtures that reduce water consumption.
Evidence-Based Design. While the volume of evidence-based design research is growing, there are still opportunities for more quantitative analysis of the benefits of design features on patient outcomes and staff well-being. Anshen+Allen Architects for Palomar Pomerado Health and PPH will use the new Palomar Medical Center West as an opportunity to collect data (through the “champion teams” and the Pebble Project Partners observation), which may help inform future projects.
The design includes same-handed patient rooms, which have potential benefits for staff and patients. Uniform layout aids in the consistency of care practices, reducing staff error and minimizing staff reaction time in high-stress situations. The campus also includes ample access to nature and daylight through terraces, balconies, roof gardens, interior courtyards, and views of the surrounding hillside, since it is believed that offering patients and staff an opportunity to engage in and connect with the outside world can improve both clinical and operational outcomes.
Building for Flexibility. The most innovative design elements of Palomar Medical Center West are those that adapt to the changing face of healthcare. The facility will feature acuity-adaptable patient units (Figure 2) and an Integrated Interventional Platform (IIP). Both are designed to accommodate a wide spectrum of patient needs and allow room for changes in healthcare practices. The acuity-adaptable patient room (Figure 3) is created to ac
commodate a range of inpatient care, from intensive to transitional, minimizing the need to transfer patients and thus reducing the risk of falls and medication/clinical errors as patients remain in the care of the same medical team.
Palomar Medical Center West will feature acuity adaptable patient units. © Anshen+Allen Architects for Palomar Pomerdo Health.
The acuity adaptable patient room is created to accommodate a range of inpatient care. © Anshen+Allen Architects for Palomar Pomerdo Health.
Adaptability to Change
Surgical and imaging procedures are rapidly converging. As minimally invasive surgery, with its use of endoscopic and robotic tools, becomes less invasive (as compared to open surgical procedures) and, simultaneously, as some forms of medical imaging become more invasive and interventional, the chasm between these “ologies” is rapidly closing4. And as these procedures become more similar, their respective specialties develop commonalities in regard to environment and equipment needs. For example, interventional imaging and surgery both require environments with controlled circulation, materials and work flow5. In a time when innovative and progressive healthcare must compete with construction costs, the IIP is the logical future, since it colocates areas that perform similar medical functions and share equipment, promoting collaboration and minimizing expensive duplications.
The IIP also is designed to support collaboration between radiologists, surgeons, and other interventional specialists. The role of imaging in healthcare is becoming more varied and widespread. Image-guided surgery, once used primarily in neurosurgery, is being adopted by other specialties; MRI-guided surgery, often referred to as Magnetic Resonance Therapy or Intraoperative Magnetic Resonance Therapy (I-MRT), is becoming useful in oncology because of its ability to differentiate between abnormal and normal tissue; and a whole array of imaging equipment is evolving with advanced technologic capabilities.
The second floor of the Diagnostics & Treatment facility (Figure 4) is designed to respect and accommodate this emerging collaboration. The floor includes a three-room Endoscopy suite, a six-room Interventional suite (Imaging Radiology/Catherization/Cardiac Catheterization Lab) adjacent to two six-room ORs, a prep and recovery zone, and “soft” space for storage/support. For the greatest degree of flexibility, all the procedure rooms share a universal design, relying mainly on portable imaging with only a few dedicated to fixed equipment (Figure 5). The prep and recovery zone is designed to accommodate any changes in zoning between the Interventional and Surgical zones, minimizing the need for major construction or work flow adjustments. The soft space next to the OR can adapt into storage, support, control, or IT rooms as the need develops. Additionally, two of the ORs were designated as a Future Advanced Technology Zone to accommodate I-MRT procedures. The entire suite has an upgraded infrastructure to accommodate the equipment, and the allocated space was identified based on work flow and adjacencies to minimize the need for major construction.
Floor plan for the second fl oor of the PPH's Diagnostics & Treatment facility. © Anshen+Allen Architects for Palomar Pomerdo Health.
To allow for the greatest degree of fl exibility, all the procedure rooms share a universal design relying mainly on portable imaging. © Anshen+Allen Architects for Palomar Pomerado Health in conjunction with BERCHTOLD Corporation and Philips Medical Systems.
The Construction Cost Crisis
The current construction climate has been deemed a cost crisis by many. Global construction challenges (rising materials costs coinciding with a sharp increase in construction demand by other countries) compounded by the building challenges specific to California (SB 1953 requirements, the Office of Statewide Health Planning and Development [OSHPD] review process, and an increase in commercial and institutional projects) have created an unfavorable building environment for California hospitals.
These conditions have created a shortage of qualified and interested contractors, especially in the San Diego area, where there is a steady supply of commercial, hospitality, educational, and other projects, which have quicker turnaround and less financial risk. Contractors who are interested often find themselves losing money on hospital projects by investing too much of their labor force and management talent on one project (one contractor had spent seven years on a single hospital), decreasing the allure of a complex hospital construction project such as Palomar Medical Center West.
With a market this formidable, it's difficult to manage a normal-sized project let alone a 922,000-square-foot campus that includes a 360-bed Medical Center, a 96-bed Women's and Children's Center, and a Central Utility Plant. Therefore, the most significant challenge is to preserve the aforementioned innovative design features while responsibly managing the project budget.
Solutions. To maintain this delicate balancing act, Anshen+Allen Architects for Palomar Pomerado Health employed two productivity and risk-control methodologies: Design-Assist and 3D/4D modeling. Design-Assist engages the builder and major specialty trades during the design process. This takes advantage of their professional expertise to determine the measure of the design's constructability (thus avoiding major design changes later when it becomes more costly) and to develop a realistic construction schedule tailored to the demands of the design. It also expedites the OSHPD review process by having the contractor available to provide coordination and shop drawings during the design phase, reducing the risk caused by permit delays and coordination-related change orders.
This approach, in conjunction with 3D and 4D modeling capabilities, moves the design to get to a constructible state much earlier in the process and minimizes costly surprises. By using virtual building techniques (including building information modeling), the project team is able to store, share, and evaluate information and decisions made during the design process. Virtual building models contain intelligent, computer-based representations of real-world objects and support the free exchange of robust physical and functional data, as well as 3D geometry. Virtual buildings support rapid, efficient, and accurate analysis of physical, environmental, and cost performance; expert input can be introduced sooner and more frequently to support superior decision making during the design process. These measures have the bonus of attracting more contractors because they foster a collaborative and cooperative environment that gives contractors more control over risks to their productivity.
The Business Case for Better Healthcare Design
“A well-planned facility cannot replace good medicine… Designed creatively, however, it can enable healthcare provid
ers] to perform their jobs to the best of their abilities…A poorly planned facility, on the other hand, can compromise the abilities of all who use it, and as such can be expensive to staff and to operate”.6
Features such as the IIP, acuity-adaptable rooms, and access to nature/daylight can, in fact, cost more. Compared to a typical acute care patient room, the acuity-adaptable room will cost Palomar Medical Center West approximately $133,254 per room (this total includes extra square footage for a family rest area and larger toilet facilities, a bed with all modules to cater to varying degrees of acuity, and additional features). Sustainable design costs—including balconies, terraces, green roofs, courtyards, skylights, sunscreens, and energy and water strategies—will add a $15.8 million premium to the construction cost. The infrastructure enhancements associated with the IIP could cost up to $6.95 million.
These costs may seem superfluous and risky considering the inflated cost of construction. However, what does it cost a hospital not to include flexible and progressive healthcare design features? The measurement of these costs must be viewed in a broader context of cost, over the life cycle of the hospital. And higher staff retention, healthier and faster healing patients, and increased market share must be taken into consideration.
In the article “Can Better Buildings Improve Care and Increase Your Financial Returns?”7 the costs of evidence-based and progressive healthcare design are quantified by the Fable Hospital (a theoretical amalgam of hospitals that had implemented evidence-based design). The article concludes that the costs of these features actually pay for themselves by reducing patient falls, medication errors, staff injury, nosocomial infections, per-patient pain medication plans, and staff turnover.
Conversely, the costs associated with a poorly designed facility, without the flexibility for the ever-changing advances of healthcare provision, include potential duplication of staff, equipment, and space, as well as future construction upgrades and associated hospital downtime.
We cannot ignore the fact that as designers, we are socially responsible to promote healthier living, improved staff comfort, and overall better healthcare in the creation or alteration of hospitals. While the initial costs of better healthcare design may be higher, the ability of design to affect positive change in the healthcare community and society as a whole makes it an intelligent and necessary expenditure. HD
Principal and Director of Research in the San Francisco office of Anshen+Allen Architects. An author of numerous books and articles on health facility design, Rostenberg frequently speaks to both medical and design professionals, such as the Radiological Society of North America (RSNA), the American College of Surgeons (ACS), The Association of Perioperative Registered Nurses (AORN), The American Hospital Association (AHA), The American Institute of Architects (AIA), and Harvard University Graduate School of Design, Office of Executive Education.
Media Services Coordinator with Anshen+Allen Architects. She has been creatively writing for architecture and technology for the last several years.
- Levin D. Design based on the evidence. HEALTHCARE DESIGN. Sept. 2002:6–7.
- Kogut L, Satko V. Planning considerations for the minimally invasive surgical suite. HEALTHCARE DESIGN. April 2006:57–60.
- Joseph A. The Impact of Light on Outcomes in Healthcare Settings. Concord Calif.:The Center for Health Design 2006:7.
- Rostenberg B. Convergence of the “ologies”. HEALTHCARE DESIGN. May 2006:42–54.
- Rostenberg B. The architecture of reform. Modern Healthcare Magazine Dec. 1, 2003:20.
- Rostenberg B. The Architecture of Medical Imaging. Hoboken New Jersey:John Wiley & Sons, Inc.; 2006:153.
- Berry L, Parker D, Coile R, et al. Can better buildings improve care and increase your financial returns? Frontiers of Health Services Management 2004; 21:19–24