On paper, Boston City Hospital and Boston University Medical Center Hospital came together in 1996 to form Boston Medical Center (BMC). But the acute care hospital and the academic teaching hospital never physically consolidated, meaning they both continued to operate programs on the same campus for several years, each with approximately 250 beds and overlapping services.

While there had been discussions about merging and building a new patient tower to meet expectations of a growing census, not much changed until a perfect storm hit: the economic downturn followed by cuts in reimbursement rates. “That’s when the inefficiencies of the campus arose as a big obstacle,” says Neal Emmer, a principal at architecture firm Levi + Wong Design Associates, Inc. (LWDA; Concord, Mass.). “That’s where a lot of their resources were going, and if they could stop or reduce the financial losses, they would have a chance to remain viable.”

Down south in Baton Rouge, La., Our Lady of the Lake Regional Medical Center, a private, not-for-profit 802-bed hospital, was facing a different challenge a few years ago: population growth. “We had the unique situation that post-Katrina we were growing in what was forecasted to be a shrinking marketplace,” says Terrie Sterling, executive vice president and chief operating officer at Our Lady of the Lake, which is part of Franciscan Missionaries of Our Lady Health System.

Part of that growth was driven by a relocated New Orleans population that chose to stay in Baton Rouge instead of move back home to a city still rebuilding. In addition, the governor of Louisiana had proposed a new public-private partnership for the state that focused on expanding medical education, retaining physicians, and increasing networks of care sites for crisis situations.

Brenda Bush-Moline, principal and healthcare director at VOA Associates Inc. (Chicago), says these shifts together put Our Lady of the Lake in a position of not worrying if patients would come. Instead, the medical center had to figure out the most efficient and cost-effective way to meet its growing demand, while identifying which service lines it should grow to remain competitive.

For both of these facilities, master planning was the answer; however, it’s become a far more complex process than ever before. “In the past, hospitals focused mainly on just the physical aspect of [master planning],” says Jonathan Gyory, a principal at LWDA. “But today, if they don’t focus on every other aspect of how it relates to community care, their relationships with doctors, and their off-site facilities–and look at this within the context of the accountable care system—they won’t be approaching it right.”

Emmer agrees: “Hospitals really have to figure out where their cost and profit centers are, what alignments they’re going to make, and what specialty service lines they’re going to offer.”

Case study: Boston Medical Center
In 2012, BMC began working with LWDA on a master plan to improve quality, efficiency, patient satisfaction, and revenue. Because more than 70 percent of its patients come from underserved populations, BMC had already established a network of neighborhood health clinics and its own healthcare plan, so it already had an accountable care organization in place.

LWDA revisited BMC’s existing master plan that was developed pre-recession to see if building a new patient tower on campus was still a viable option or whether the organization could renovate in place and still meet its goals. New demographic and volume studies showed that its post-recession census wasn’t growing, but it also wasn’t shrinking. Faced with declining reimbursement rates, the team suggested that BMC could shore up its finances by consolidating services, aligning departments, and improving its campus infrastructure to be more energy efficient—changes that are expected to save the owner $30 million a year.

The master plan calls for 500,000 square feet of renovations and 100,000 square feet of new infill construction across four main buildings on a fully occupied campus. A series of enabling projects started in 2013 to move departments and administrative space that had been mixed in with clinical space to other buildings so that renovation work could begin. The whole campus build-out is expected to be completed by early 2019.

To address the duplicate campus set-up, planners decided to spin off the former Boston University facilities into research and education space and centralize all of the acute care services, including surgery, emergency, and radiology, at the old Boston City campus (renamed the Menino campus).

Inside the hospital, a review of visitor circulation and departmental volumes was conducted to right-size spaces, such as the cafeteria and gift shop. Departmental adjacencies were also studied and shortened and wayfinding was clarified—for example, admitting was relocated between two main buildings to better capture patient traffic upon entering the hospital. The master plan also calls for relocating urgent care adjacent to the ED for greater operational flexibility, a goal that will be achieved once the ED is renovated and expanded by 2017.

In addition to improving its current-day operations, the master plan was also an opportunity to ensure future growth by looking at land and buildings within a six-block radius that BMC owned and identifying parcels to sell off, those that could be used for off-site support facilities and administrative offices, and ones that should be preserved for future development 5-10 years down the road. “Unlike many other hospitals, they did have infill sites, underutilized space, the ability to renovate parts of the campus and move key departments to new locations, which allowed them to renovate in place and not build a new tower,” says LWDA president Thomas Levi. “Not everyone has that opportunity.”

Case study: Our Lady of the Lake Regional Medical Center
On the Our Lady of the Lake campus, the master planning team needed to address several goals, including becoming a clinical site for Louisiana State University’s (LSU) Baton Rouge-based physician training and graduate medical education program, bringing a heart institute on campus, and expanding its cancer care and children’s hospital. “It became very clear that the real challenge was that we were going to have to add capacity to the campus and how we would do that,” Sterling says.

For starters, the master plan identified building sites for a new 120-bed Heart and Vascular Institute building and a new Level 1 trauma center at the hospital, both of which were completed in 2014. The LSU Medical Education and Innovation Center was situated on campus to create synergy among the medical staff and student residents.

Next, the planners addressed the hospital’s growing cancer care offerings, including a partnership with provider Mary Bird Perkins Cancer Center, to offer patients comprehensive services within a modern, patient-friendly facility (renamed the Mary Bird Perkins Our Lady of the Lake Cancer Center). The exterior of the building was expanded to create a new front door. To improve circulation and patient satisfaction, new hallways and passages were built where campus buildings connect. “Prior to a procedure, a person is scared, and if they come in the wrong door, we don’t want to tell them they have to get back in their car and drive around to the correct front door,” Sterling says.

Like BMC, Our Lady of the Lake also wanted to anticipate the long term by creating a master plan that looked 20 years out. Planners turned to an undeveloped area on the east side of the campus as a potential site for a future freestanding cancer care building, where a growing demand for services might be answered. More immediately, ho
wever, VOA proposed building a new freestanding children’s hospital. “Despite the fact that we are the second largest provider to children in the state, [the service] was embedded in an 802-bed medical center,” Sterling says. “From that perspective, it was difficult to have the level of distinction and process that we wanted.”

Building a new facility would mean duplicating some services, but it would also provide an opportunity to improve care and create a medical destination that would attract patients as well as staff—a critical need in today’s ever-competitive marketplace. Sterling says the new hospital, which has a target opening date of 2018-2020, is being designed with increased bed capacity and will also have shell space to accommodate growth. Once that building is constructed, Sterling says an existing children’s ED will be converted into an urgent care center to help the operator compete with the growing number of nontraditional providers entering the market, such as MinuteClinic and Wal-Mart.

Like many healthcare organizations today, Our Lady of the Lake also had to look at extending its reach further into the community. The master planning process included identifying a series of outpatient centers in nearby residential areas that would refer into the main campus, including construction of a freestanding ED about 20 miles from the main campus in one of the area’s fastest-growing neighborhoods. Sterling says the facility features a physician tower and has the ability to house beds in the future, but for now it will serve as a referral site to the main campus. The medical center has also developed a relationship with a sister hospital to the south of its campus that sends tertiary cases its way. “We expect that to continue to be a model,” she says. “We want to build outpatient centers and practices, but we’re thoughtful about where we build bricks and mortar for inpatient beds.”

Staying flexible
As more facilities rethink their services and right-size their campuses, architecture firms have the opportunity to play a bigger role in helping them plan for the future and decide whether to build new or reuse existing properties, design for fewer beds, or provide a new mix of services.

Sterling says she appreciated that VOA not only helped Our Lady of the Lake plan for their immediate needs, but also provided the organization with some future options, such as where to add parking garage capacity if the need arises or options on where to locate a medical building on campus. “It really helped us think about not only the consumer and patient needs but our team member needs and our business needs,” she says.

VOA’s Bush-Moline says accounting for flexibility is one of the biggest challenges in master planning today. “You want to be careful with how much flex you provide because at the end of the day, you’re trying to create these tailored, meaningful places that are brand-specific environments. If it becomes too flexible, it loses that panache.”

Keeping up with the pace of technology, evolving mandates from the Affordable Care Act, and the drive for patient-centered care will also keep planners and facilities on alert for a while, operators and architects say. “Nationally, everyone is really just trying to understand what’s being asked of them and how they’re going to align themselves and make internal changes to run their business,” says LWDA’s Levi .

One of the keys to success is an understanding that master planning is an iterative process. “A good plan is a living thing,” Sterling says. “It’s not on a shelf somewhere.”

Anne DiNardo is senior editor of Healthcare Design. She can be reached at adinardo@vendomegrp.com.