Is it still possible to provide an efficiently designed healthcare facility that makes a meaningful impact? Between the ever-changing federal regulations, sustainable design ideas, a growing elderly patient population, and skyrocketing operational costs, the challenges are certainly daunting.

“Thirty years ago, it was about making a nice new wing,” says Bruce Knepper, vice president of healthcare at Stantec. “Now, we’re involved with, ‘What’s the cost, what’s the new program, what’s the new wing, and can you optimize it for efficiency?’”

In short, the design focus is no longer just on being good-looking; it’s both good-looking and smart.

No choice but to expand
New designs and renovations can happen in two ways. The first is when hospital executives decide what to build and move forward with a planning committee and eventual Request for Qualification (RFQ). It’s a cut-and-dry proactive scenario that probably doesn’t happen as often as architects would like.

Needs-identified upgrades are much more common and typically occur when one department organically pushes into another through unanticipated demand for services. When this happens, planning consultants will research strategic business solutions incorporating current market share, operational costs, and efficiency designs for better post-construction revenues.

LEED-certified buildings are one way to go but are more expensive than pursuing a regular sustainable design. What about the patient population? Are there enough elderly patients to justify a wayfinding design?

Renovations involving multiple buildings constructed over the course of several decades often come with their own set of snags. “Most hospitals are built on a ‘fumble approach’ from the 1920s. The architect comes along, and now there are 40 or 50 years worth of buildings, all of which have a different appearance and aesthetics,” Knepper says. “What do you do? Do you make it blend? Do you make a statement?”

Sometimes it’s not the department overflow but personnel influencing the end design. Richard Sprow, principal and healthcare practice area leader at Perkins Eastman, remembers how a 26-bed facility conversion design near Jackson Hole, Wyoming, had to revolve around nighttime staffing levels.

“We had one nurse available to watch the front door, the back door, the nursery—everything. It drove the need for a low-cost design because everything was centered on the nurses’s station," he says.

Yet even straightforward additions are never really that simple. Todd Freed, vice president of healthcare at the Hunt Construction Group, recalls a vertical and surgery expansion project he completed for Bassett Healthcare in Cooperstown, New York, that first required seismic retrofitting.

“People don’t realize that New York is in a seismic zone. Before putting this vertical expansion on top of a six-story hospital, we had to first seismically retrofit the entire building all while keeping [the facility] operational," he says.

The kind of design, impacted departments, and type of currently existing building structures all mean proposals can undergo several rounds of modifications before a final decision is made.

Making it work before the work starts
“The pre-schematic design is the most challenging,” Sprow says. “You’re dealing with a specific number of rooms, specific square footage, functional relationships, and the architectural characteristics of the building—you’re trying to conceptualize a project addressing all the pushing and pulling that happens.”

The key to successfully combining a new design with current architectural and staffing demands is simple: clear communication between all parties involved.

“We always have to work as a three-legged stool,” Freed agrees. “It’s critical. If one leg is out of balance, the whole thing comes crashing down.”

For Freed, a successful Bassett Healthcare project meant almost three months of preplanning presentations and corridor taping to designate infection control barrier placements. “Not everyone can look at a plan and understand it. In our business, so much of the heavy lifting is the planning prior to the start.”

Technology is another way architects are easing the pre-schematic heavy lifting. Where traditional plans once relied upon two-dimensional drawings, building information modeling (BIM) offers a 3-D approach to understanding how all aspects of a design such as width, height, depth, space, light, and even building components fit together.

The software also detects potential construction snags early on, thus reducing the risk of unexpected cost overruns.

“We are early adopters of BIM,” says Ted Moore, a project design principal in the Haskell Company’s healthcare division. He points out that from improved cost estimation to immediate redesign in the field, “BIM allows us to do more with less than a traditional project that required teams twice as large, took twice as long, and still weren’t as coordinated.”

Facilities are only as efficient as the end user
Efficient, cost-saving designs are only as effective as the people using them once the architect and the construction crew are gone.

“You are always designing for the patient, but those who are often forgotten are the facilities people,” Freed points out, noting that careful attention is typically paid to placing large pieces of equipment but not necessarily to items behind walls and above ceilings. “When you design a facility and valves are in the patient room instead of out in the hallway, this means equipment maintenance must be done in the patient room.”

The value of end-user training must not be underestimated, either. There are nuances to equipment, floors, or even different finishes that must be explained and taught.

Housekeeping staff may need to know how to clean a certain type of surgery. The facilities department may need to know how to access and change a new kind of air filter.

“When people don’t live and breathe the technology on a daily basis, you have to get the information down to the men and women who do use it,” Freed advises.

By offering multiple training sessions and providing a binder complete with a list of the newly installed equipment, associated warranties, and any operation and maintenance manuals, taking the three-legged stool approach to end-user training insures a new design will work as efficiently in practice as it did in theory.

Looking to the future
The challenges are unmistakable. Today’s healthcare architects are tasked with creating a patient-focused design that also maximizes bottom line operational dollars and cents. Anything less means design bid elimination.

“Hospitals are very concerned about reimbursements now and anything they do in their facility, they want to make sure their dollars are going as far as possible,” Freed says. “The architect who isn’t concerned about designing and spending the hospital’s money in the best way possible will not get invited back.”

Yet despite the pragmatic pressures, the future looks positive for healthcare design. “Things are getting better,” Moore says. “Whether or not you agree with the healthcare bill, there are a lot of things getting done to make healthcare more efficient and
patient-focused, these are all great things.”

“The healthcare facility design industry is open to a lot of new ideas,” Sprow agrees. “The recession and the change in the economy and change in priorities mean a lot of old, embedded ideas of facility design have suddenly gone by the wayside—the openness in the industry is really exciting.” HCD

Gwynneth Anderson is a freelance business writer specializing in finance and operations. She can be reached at