A fitting metaphor: In a phased healthcare renovation, the building serves as the patient undergoing a radical surgical procedure. The operation must be meticulously planned, since whatever part of the building is being opened and repaired or replaced is connected to the rest of the building’s systems, all of which must be monitored and kept functioning.

The process is far more complicated than simply gutting a building, because phasing requires precise timing by an entire team of professionals.

Although it’s become far more common for architects working on all types of projects to collaborate with contractors and building owners right from the start of planning, a design charrette alone would  have been insufficient on a project of the scope of the new joint replacement center at Lawrence + Memorial Hospital in New London, Conn. Involving the renovation of an existing 12,000-square-foot unit and an addition of 4,500 square feet onto the adjacent roof of an ambulatory care building, the project needed buy-in by the hospital staffers who would keep the unit operating throughout the renovation. For that reason, integrated project delivery (IPD) was the delivery method chosen, bringing stakeholders together contractually and laying the foundation for a successful Lean process.

Joint venture
Lean construction and the production preparation process (3P) both have their roots in manufacturing, but they’ve been successfully applied to many other areas of design. With a primary focus on eliminating waste in processes, their precepts are ideal for utilization in phased healthcare renovations.

Taking part in early workshops where these approaches were used, Lawrence + Memorial Hospital’s staff helped develop the project’s phasing, cost implications, and schedule. With the contractor, A/Z Corp. (North Stonington, Conn.), mocking up spaces and working with designers on details as each idea was floated, a budget was developed in real time that kept the planning on target.

The joint center started as a fourth-floor, 30-bed unit, but the rooms were primarily double occupancy, a situation that the hospital’s surgeons in particular argued was inconsistent with modern standards. A key goal therefore became to create more private rooms rather than add beds, and attention quickly turned to the adjoining three-story ambulatory care building. Originally designed to accommodate three additional floors, the building underwent a structural analysis that determined the building could safely handle an additional 4,500 square feet without requiring any expensive structural upgrades. Although the scope of the addition had been capped for budgetary reasons, the added space allowed for a shift from 12 private rooms to 22.

The addition included five private rooms arrayed around a nurses’ station; rooms for medications, soiled linens, equipment, and staff restrooms; and a family lounge/waiting area sited so visitors can soak up southwest-facing sunlight.

There was concern by some of the nurses participating in the 3P workshops that the addition might seem isolated from the rest of the unit, but an open plan was created to allay those fears. The addition links to the main corridor of the existing unit and can also be accessed from ambulatory care below, using an existing staircase. Meanwhile, the five private rooms’ doorways are all visible from the nurses’ station.

Nine months
Modernizing the care environment involved many relatively simple materials and techniques, but the challenge existed in accomplishing the renovation in an operational hospital, with the number of available beds in each phase at about two-thirds the existing total. The project was organized into three phases, each lasting between two and three months. Prior to demolition work, each phase began with the establishment of a construction perimeter and negative air pressure in adjacent spaces, and the coordination of sanitary piping connections with other floors.

Phase 1 focused on the renovation of 11 private rooms and toilet rooms, and the construction of a new soiled utility room, nourishment center, storage area, and medication locations. As with subsequent phases, renovated rooms received new ceilings, floors, wall finishes, doors, fixtures, and lighting, and toilet rooms were redesigned and enlarged where necessary to meet modern codes.

Also in Phase 1, half of the nurse’s station was converted into a new decentralized nurses’ station and enclosed charting room, while the other half temporarily remained in operation. This necessitated construction of a temporary wall that bisected the existing station.

With this phase scheduled to wrap up at the end of 2012, hospital administrators agreed to shut down the entire unit the last 10 days of December, allowing to the team to complete some overlapping areas, such as the main access corridor.

Phase 2 then included renovation of the other half of the nurses’ station, a second corridor linking to the main corridor, and two observation rooms and toilet rooms. Three shared rooms were converted into one semiprivate and two private rooms. New construction included a central bath, a temporary nurses’ station, and support spaces for the new nurses’ station.

Finally, Phase 3 allowed for renovation of the balance of rooms, including one observation room, as three semiprivate rooms were converted to private rooms. A rehab gym was also added, and additional support areas (clean storage, equipment storage and staff lounge, and toilet room) were completed. The bulk of the addition took place during Phase 3, although the complexity of the addition meant that much of the new construction occurred concurrent to the initial two phases.

All together now
Integrated project delivery benefited the project throughout the renovation. The initial partnership between designers, contractors, and the owner shortened the project time frame—there was no bid process, and drawings were developed in real time, making an extensive set of documents unnecessary. The continued presence of all stakeholders at the table throughout the three phases aided immensely in cooperation and communication.

Hospital staff was not only counted on to help construction stay on schedule, but their presence in meetings led to more workable scheduling all around. During each phase of renovation, staffers were responsible for shutting down portions of the unit and relocating certain services, and for keeping patients apprised—both in the joint unit and in affected units above and below—of various construction circumstances (for example, power and plumbing shutdowns).

In the end, the hospital completed the joint center at a cost of about $230 per square foot, with no change orders and within its original schedule.


Jim Bell is a partner with Moser Pilon Nelson Architects (Wethersfield, Conn.) He can be reached at jbell@mpn-arch.com.