Saving a community hospital
The current crisis in healthcare is not limited to issues of access, reimbursement, and soaring costs. Among primary healthcare deliverers there exists a crisis in facilities that is every bit as acute. In the Southeastern United States especially, many small, rural hospitals are struggling with facilities constructed during the boom years of the 1940s, 1950s, and 1960s when the Hill-Burton federal support program funded hospitals in a wholesale fashion. Now most, if not all, of these facilities have reached or exceeded their practical life expectancies. Regeneration, restoration, and replacement of these aging facilities have become a critical need—unfortunately, without the largesse of the now-defunct Hill-Burton financing program.
Nevertheless, rural hospitals are forging ahead—although, regrettably, we often see a one-size-fits-all mentality in facing the challenge of facility replacement. Many proposed projects simplistically propose scaled-down versions of larger referral and even tertiary care centers as a solution. Unfortunately, these “solutions” usually yield project costs in the $250- to $300-per-square-foot range, often beyond the practical resources of rural facilities.
Such a situation evolved early in the development of a replacement project for the Abbeville County Memorial Hospital (now known as the Abbeville Area Medical Center) in Abbeville, South Carolina. An excellent replacement program proposed by AHFD consultants of Brentwood, Tennessee, yielded a prospective project cost of nearly $240 per square foot (in 1999 dollars). Routine approaches to financing a project of such magnitude were ineffective. The hospital existed in an economically depressed, no-growth area and had limited capital reserves. A local referendum failed, and an assessment of financial capacity yielded a maximum capacity of around $200 per square foot in total development costs.
This project price point was, in fact, achieved in the summer of 2006; how this happened is the subject of this article.
Before launching into a description of this project, it would be beneficial to offer our understanding of the meaning of “primary care” in the context of rural facilities. Most primary care occurs on an outpatient basis. Accordingly, diagnostic and treatment services may be housed in facilities not unlike those developed for freestanding diagnostic and treatment centers, specialty medical clinics, and ambulatory surgery centers. The inpatient constituents of primary care require simple, uncomplicated medical support services. Often these patients are held for observation before they are transferred to more sophisticated healthcare environments. Others might be recovering from serious but minor operative procedures. Even in critical care environments, the intensity of care is more often related to close observation rather than to aggressive intervention.
Diagnostic and treatment services in this environment are largely investigative and employ relatively uncomplicated equipment and minimal technical and professional staff. Most important in these areas is easy access to referral centers for assistance in interpretation of diagnoses that may be beyond the capabilities of the attending caregiver. For this reason, access to high-speed communications and picture-archiving x-ray technology is far more important than access to such equipment as state-of-the-art CT scanners.
Similarly, inpatient rooms do not require sophisticated headwall systems, multiple medical gas capability, or complicated vital monitoring components. One consultant we work with has likened these environments to an “upscale motel room with gases.” However, adequacy of space for patients and care partners, accessible toileting and bathing facilities, and individualized environmental controls are important.
Administrative support services are essential to smooth operations and include offices for administrators and governance, fiscal services, medical records, human resources, quality assurance, and volunteer accommodations. All of these functions are easily housed in detached conventional office buildings, and the proximity to the clinical areas is enhanced by the overall reduced size of the facility.
Finally, one of the largest areas of the rural hospital includes building support services: materials management, food service, environmental services, plant operations, and electro-mechanical areas. Their size is often dictated not by need but by regulatory requirements, such as 72-hour availability of alternative energy fuels and food stores to nourish an entire complement of patients and staff during a weather emergency. Such provisions are easily accommodated in simple structures designed to industrial standards.
What evolves from these premises, therefore, is the notion of four separate building types, linked by an infrastructure of enclosed and air-conditioned building connectors and code-mandated fire separations. Although the architect may specify consistency of cladding for each of the components, internally the structure materials and systems may be radically different from each other. Such was the basis of design for the Abbeville replacement hospital.
Project Delivery System
Once the decision is made to proceed with a project, stakeholder buy-in is critical. At Abbeville, the project kickoff meeting involved every department of the hospital. The concept, as well as budgetary restraints, were presented and reviewed in detail with all hospital personnel. Senior administration established a clear chain of command for decision making, and the CEO became directly involved as the final arbiter of any proposed changes in scope. The goal of this and subsequent sessions was to continually reassure all stakeholders that their areas of interest were being addressed fairly and without preference being given to one department at the expense of another.
As the architectural plans were finalized, the engineers were tasked to similarly evaluate the system needs of HVAC, plumbing, electrical, and communications. Here the mandate was to simplify wherever possible to achieve benefits of reduced first cost and operating efficiency. Accordingly, each of the four project components received HVAC systems appropriate to their function—for example, patient rooms are serviced by individual room heating and air-conditioning units similar to those found in upscale motels, enabling the components to operate independently of each other. Components such as administrative functions operate on a different schedule from those related to support services or direct patient care, but all the systems can be modulated and even shut down without elaborate control systems and their attendant need for specialized maintenance services.
Similarly, the construction site must be organized to optimize implementation efficiency. Here, the selection of a construction delivery system is crucial. The conventional design-bid-build system is not only inefficient but suffers from the lack of project leadership and singular accountability. If independence of design and construction is mandated, then the presence of a knowledgeable program manager such as AHFD—with no vested interest in either the design or construction—is an absolute necessity to effect project compliance within program intent and budget. Alternatively, a sole- source design-build contract led by responsible design professionals can also create a successful project, often at the least possible cost. Such a selection depends on a well-established relationship of trust among the parties. Design-build was the methodology chosen to implement the Abbeville project
Planning the on-site activities implementation should involve the optimization of component delivery. Cost savings can accrue by bringing components to the site when needed in lieu of on-site inventory of materials in advance of need. Site security measures are reduced, product damage is minimized, and product loss is avoided if materials are brought to the site and installed without warehousing. This technique is widely used in the construction industry, and through competent project management and scheduling there is no reason why this modern technique cannot be used even on a complicated healthcare construction site.
Similarly, the program manager—or in the case of design-build, the construction project manager—must be empowered to control the efforts of subcontractors. Countless dollars are expended unnecessarily on many construction sites through improper scheduling of subcontract work without cross-coordination. Damage to materials in place by other trades can be avoided through proper advance scheduling of subcontractors. Finally, costly rework of incorrect installations is avoidable under the supervision of a knowledgeable and authoritative project site superintendent.
Project Success Factors
Ultimately, the success of any project stems from the owner's integration into the process throughout design and construction. At every milestone in the process, the owner's governance, administration, and caregiving staff must be advised and alerted to decisions to be made to assure project success. During construction, the budget may need to adapt to industry changes in material and labor costs. In all cases, owner representatives need to be advised continually to make informed decisions.
For example, the Abbeville Board of Trustees voted to delete a “cosmetic” architectural feature to fund the purchase of a much more critical piece of medical equipment not anticipated at the outset. The design-build team brought this proposal to the attention of administration, notwithstanding the ensuing loss of both design and construction fees. Such a cooperative and self-sacrificing spirit would be unthinkable in a conventional low-bid scenario.
In hospital construction, the role of regulatory agencies is often crucial to a project's success. Frequent interface with site inspectors throughout the construction process can assure that costly final interpretative code modifications are avoided. Often code officials are unaware of the benefits of new technologies and materials. A case in point at Abbeville was the use of PVC waste piping in lieu of cast iron. Instead of blindly pressing ahead, the design-build team involved the local code officials in the proposed change early in the process and presented statistical evidence of the longevity and dependability of PVC piping to gain support for the proposed product.
Hospitals, unlike most every other building type, are unique in that they operate 24 hours per day, 7 days per week. In a very short time, the smell of new paint and carpet is gone and the facility becomes an integrated component of the community's healthcare delivery system. Accordingly, adaptability becomes a paramount demand upon the facility. Changes in technology and volume and character of service can occur within months of a facility's coming on line. The facility needs the capability to react to these changes without enjoying the luxury (i.e., the ultimate flexibility) of a vacant building. Once occupied, a healthcare facility exerts its own demands on change with regard to barrier management, infection control, and phasing for continuity of operations. If the design has been conceived to consider these future needs, its success will be continuing. If not, the facility will ultimately experience the same fate as that of the facility it replaced.
Abbeville Area Medical Center is designed so that each of the major components can expand independently of the others. Separate departments within each component are similarly provisioned. For example, both the emergency and radiology departments can be expanded along their outer edges without affecting other areas of the facility.
Integrating the community and its constituents is another element of project success. Throughout the construction process and long before the grand opening, Abbeville administrators gave updates and progress reports at town meetings and public events. A formal public relations campaign was instituted to acquaint the community with the features of the new facility and the advances in healthcare delivery contemplated therein. The strategy all along has been to inculcate within the community a sense of ownership to encourage use of the facility in lieu of more familiar but distal alternative health delivery services the community has long been forced to endure.
One crucial constituent to be included in the process is the physician community serving the hospital. Like the general population in the area, physicians increasingly chose not to practice at the deteriorating aging hospital but needed to be assured that changing their environment and practice patterns was desirable. Many meetings were held with physicians, both individually and in groups, to secure their input and endorsement. In response to the proposed project, many of these physicians have chosen to create satellite facilities for their practices in the immediate vicinity. This represents another critical component in the ultimate success of the Abbeville project.
Even with the ongoing involvement and participation of all hospital stakeholders in the project, a formal orientation and start-up process is essential to enjoying a “running start” in the new facility. The design-build team or the program manager must be prepared to provide lengthy and comprehensive guidance in the use of the building(s). For many stakeholders it will be a wholly new experience in highly advanced systems and procedures compared to those they have been accustomed to as they coped with their aging facility. One can liken the process to moving from a mechanical automobile of the 1950s to the computer-assisted, electronically controlled vehicle of the 21st century. While the basic operating parameters may be the same, the technology and control interfaces are totally foreign. The systems in the replacement hospital, although more sophisticated, were not so complicated as to require a formal commissioning process.
The new Abbeville Area Medical Center exemplifies how architecture met a community's need for advanced healthcare. It truly does take a village, and in this small, rural town, the healthcare design village achieved a high-quality continuation of services as it entered the 21st century. HD
Valentine A. Satko, AIA, is a senior healthcare planner and design principal at GMK Associates, Inc., Columbia, South Carolina, a design-build firm specializing in healthcare facilities in the Carolinas and Georgia.