Today, it’s a “do-more-with-less” world in healthcare. It gets even more complicated with funding shortfalls. How can today’s hospitals achieve highest value from their capital improvement programs despite inevitable spending barriers? It is a dilemma.

The key is proper planning. In almost 50 years in the business, KMD has seen many mistakes when it comes to healthcare systems. Relying on decades of experience, we have identified four strategies to increase choices, confidence, and flexibility, all of which can be used separately or in combination to offer administrators more control and predictability. 

Strategy 1: Think bigger picture
It is difficult to step out of the narrow confines of your perspective and see the proverbial forest for the trees. However, when it comes to healthcare capital improvements, there is much to be gained from pulling back and taking a 30,000-foot view of the entire national park.

Market studies and projections should drive long-term institutional goals. But here is the key: The system doesn’t have to go down this path alone. Strategic partnering opportunities exist in the very communities for which the system serves, opportunities that create win-win-win strategies to add value and lower costs for all the partnered entities.

One successful example is the transformation of a 1960s county-owned-and-operated hospital in El Paso, Texas, into the much larger University Medical Center (UMC) of El Paso. The hospital’s leadership and the county government came together and decided to expand and modernize the existing hospital through a county bond election.

Such community-wide resolve helped convince Texas Tech University to expand its El Paso Health Sciences Campus, establish a new four-year medical school, and announce a new school of nursing. Then, the City of El Paso created a 440-acre enterprise zone to attract medical, pharmacological, and informatics entities to the future site.

The project was well underway when the U.S. Department of Defense selected Fort Bliss to be one of its major military bases, which stimulated the local economy with expanded population and construction. Through greatly improved management, the hospital district was able to show a consistent annual operating profit, provide an increasing array of new services, and meet the needs of indigent patients without seeking increases in the parcel tax paid by county property owners.

These situations together created a positive climate to attain yet another long-term community dream—a children’s hospital for El Paso that was subsequently approved by voters in 2008. The entire program of expanding and revitalizing UMC and opening El Paso Children's Hospital was undertaken by the KMD Architects design team in 2006 and completed in early 2012.

UMC now has a reputation as a prestigious academic medical center and a revitalized campus. This is a win-win-win for all the strategic partners.


Strategy 2: Options, options, options
Options are the life blood of a good facility master plan. They offer decision-makers the freedom of choice when you arrive at a fork in the road of future scenarios. Creating multiple options and vetting them equally allows the healthcare system to undergo an apples-to-apples comparison in relation to the stated goals of the project.

KMD planners analyze each option across a wide range of scenarios that the healthcare system may encounter. These scenarios include industry-wide trends, community changes in demographics, economic trends, prospective new legislation, and—not to be forgotten—the healthcare system’s competition.

For physical planning and design alternatives, we establish criteria appropriate to the options at hand. Capital cost, life cycle cost, potential operational savings, and even aspects of sustainability are all important components to weigh.

In order to assess and summarize their performance, it is helpful to employ a matrix matching all integrated business and facility options under a full range of scenarios for the future. Through this process, we ascertain which options will respond best to the full gamut of good and bad times, high and low levels of reimbursement, positive or negative community acceptance, and the behavior of potential competitors.

This process was employed successfully to analyze various building configurations for the new replacement acute care pavilion at El Camino Hospital in Mountain View, California. Building options varied from a tall, vertically stacked structure with minimal site coverage to those with a lower profile that covered much more ground.

Through the process, several influential criteria emerged that influenced consensus on a preferable configuration. Tall buildings of more than seven levels would not respond well during seismic events, required more steel, and would therefore cost considerably more than low-rise options. This process revealed that a lower silhouette offered floors of sufficient size to achieve ideal departmental adjacencies.

By examining all of the options equally, the team settled on a configuration of five levels that met both community expectations and hospital needs.


Strategy 3: Open areas create flexible options
Upon selection of the preferred alternative, the next challenge is facility flexibility. Whether it is patient rooms, highly specialized surgeries, or common areas, each component presents intrinsic and important issues driving its size and orientation.

It is similar to training for optimal strength and endurance. Sure, you can go to the gym every day and bench press your body weight, but focusing solely on building upper body strength doesn’t do anything to increase the amount of weight you can squat or how fast you can run.

Instead, it is the process of cross training that allows your body to efficiently reach its full potential of physical fitness. The same is true with healthcare systems; you want to be healthy enough to flex your muscles.

At the Memorial Sloan-Kettering Cancer Center in New York City, a growing demand for larger and more flexible procedure rooms resulted in a plan to create a new interventional platform at the sixth floor, across the five existing buildings. To respond to this demand, a rooftop two-directional truss was incorporated that spanned the 175-foot-by-225-foot area, resting on four large columns driven to bedrock below.

This created optimal flexibility for KMD to accommodate 15 of the 21 new larger surgeries.

Locating all 21 surgeries around one central sterile core would require an extremely long peripheral corridor to reach every room. Instead, KMD suggested clusters of three, four, and six rooms around smaller sterile cores. Each core would be equipped to serve many specialties and all can share staff, equipment, and supplies.

Post-occupancy evaluations have shown that each cluster operates with more efficiency and with improved staff morale than previously achieved in a traditional cluster of 16 rooms around one sterile core.

Additionally, planning spatial flexibility into the room sizes enables uses for the space to change throughout the life of the rooms. The early analysis indicated the need for 15 new 800-square-foot operating rooms and six 6
00-square-foot rooms for less complex procedures.

To meet new, anticipated technologies, four rooms accessible from the street below are planned to accommodate future MRI magnets. Two interior rooms for robotic intraoperative radiation therapy were placed where the weight of the high level of lead shielding could best be supported by existing columns.

Minor modifications were made for orthopedics and specialties with unique equipment requirements.


Strategy 4: Build capacity to match future demand
On an annual basis, the cost of hospital operations is approximately 10 times higher than all capital investment programs. It is therefore essential to leverage this investment to the extent possible to support long-term operational efficiency. So how does one do that?

First off, try not to paint yourself into a corner by only looking at your immediate needs. Estimating what services will be needed in the future, when they will be required, and how much space will be required is essential. Planning for too little capacity can result in a loss of opportunity or revenue, but over-building can reduce operational efficiency by expanding staff and patients into oversized departments. It requires a thoughtful approach and a little foresight.

To achieve long-term cost benefits, you must look at the bigger picture to avoid building a series of small incremental additions. The overall plan must be developed to accommodate changing needs while sustaining key operational relationships for the full complement of services over the foreseeable future.

Incorporating larger elements that include some unused or shelled space can allow immediate response to unanticipated needs until all vacant space has been put into service and a subsequent phase of additional expansion becomes necessary.

Here’s where your design team can flex its creative muscles to help you in your task of responsibly planning for the future by creating smaller, “bite-sized” projects that can be built over a longer timeframe, all within a facility complex that supports proper proximities and circulation patterns among programs, and utilizes land efficiently.

Ways to use space include leaving an unfinished cell as well as locating “soft” program elements, such as administrative, clerical, or education, in areas destined for future expansion of the “hard” program, such as the surgical core or the imaging department. Larger moves may be achieved by shelling entire floors to ensure that key departmental interdependencies are maintained into the future.

A building with several shelled floors can maximize the scaled use of a specific parcel of land, as compared to the neighboring buildings.

The most recent expansion for the John Muir Medical Center in Concord, California, implemented nearly all such strategies in a new bed tower addition that opened in the fall of 2010. A value design exercise aimed at reducing overall cost could have substantially risked scope; however, the process considered a full range of proposed alternatives, reviewing each in proper context and then approving or rejecting them.

During this exercise, it became apparent that a shelled basement offered a perfect location for an interventional cath lab suite. Two shelled tower floors allowed for the future addition of 32 acute care beds and a 24-bed ICU. All of these coincided with the realization that there were no plans for another significant building for many years.

The shell space offers a cushion to add 56 beds to accommodate growth and/or the opportunity to convert all existing two-bed rooms elsewhere in the hospital to single care. This gives John Muir Medical Center a competitive advantage over competing hospitals.

Given the site’s unique subsoil conditions, the addition of the basement improved cost effectiveness by simplifying the construction of the foundations. The construction of the basement quickly led to the build-out of the cath lab suite as an important adjunct within the Cardiac Center of Excellence.


In conclusion, while it may seem to be a daunting task to maximize your hospital system’s value in this current economic climate, there are a number of strategies you can employ to help. By stepping back and taking a 30,000-foot view of your system within the community in which it’s placed, you’re able to identify creative strategies that benefit a larger audience.

Additionally, considering multiple options allows for creative solutions to be uncovered, and constructing flexible floor plate configurations can achieve immediate efficiencies and reduce cost over time.

Finally, as much as you can, look ahead to anticipate growth and future needs under a variety of possible circumstances. Armed with these strategies, you can face service and budget constraints, and trust that flexible planning and disciplined implementation is helping to support the fulfillment of your long-term goals. 

Lari Diaz is a Principal-Healthcare at KMD Architects. For more information, please visit