In the face of constrained capital, many hospitals are in need of updates to their infrastructure, medical equipment, and mechanical systems. Furthermore, older hospitals are facing a number of problems including a lack of interstitial space, low floor-to-ceiling heights, and various structural issues that call into question whether renovation in the modern medical environment is even possible, let alone economical. But the question of whether to renovate or build a new facility is not always cut and dry.

Dan Becker, AIA, ACHA, LEED AP, Senior Project Manager/Planner, Plunkett Raysich Architects, LLP, and Michael Scherbel, AIA, NCARB, Partner of Healthcare Design, Plunkett Raysich Architects, LLP, will answer some of the questions facing administrators when they present “Best Practices for Complicated, Phased Renovation/Expansion Projects” at HEALTHCARE DESIGN.10. The session will be held from 10:30 to 11:30 a.m. in Room 313.

HCD: Could you tell me a little bit about Plunkett Raysich Architects, LLP?

Michael Scherbel, AIA, NCARB: Plunkett Raysich is celebrating its 75th anniversary this year. A little bit more than 50% of our business is in healthcare, which includes the long-term care side of the business, which is nursing homes, assisted living, RCAC, community living centers, as well as hospitals, clinics, and medical office buildings. We’re located in Milwaukee and Madison, Wisconsin. We have about 80 staff—architects

and interiors.

HCD: What are some of the infrastructure issues that are facing current hospitals?

Dan Becker, AIA, ACHA, LEED AP: Things such as low floor-to-floor height; narrow structural bays; mechanical systems that are outdated and aged; multiple additions, so there isn’t one clean floorplate; asbestos problems and lead abatement—we find a lot of that in many of the older facilities; any of the physical characteristics of the building having to do with life-safety issues, exiting and smoke departments not being clearly defined. That’s pretty much an overview of what we run into on a regular basis.

HCD: Is there one problem in particular that seems to affect most buildings or gives you the most trouble?

Becker: For me, it’s primarily the floor-to-floor height and the narrow structural bays. A lot of the old facilities are narrow-plate buildings with double-loaded corridors and they don’t lend themselves to outpatient-type services, necessarily. So a lot of the time, we have to adapt that to state-of-the-art facilities. That’s one of the key challenges: How do you take those existing configurations and make them work? It’s always a balancing act between an existing facility and how much money you’d have to put into it versus building new. That’s always the debate. That’s really what we’re focusing on because every hospital and every board runs into the same quandary: What do we do?

Scherbel: I think Dan is right in that the structure itself dictates a clinical response. Today, everyone is looking to try and be more efficient in their delivery of care and a long linear building is going to predicate your efficiency. It’s generating greater footsteps for staff and physicians, and wayfinding challenges for patients who may only come to the facility occasionally. And once the patients are where they need to be, it creates greater inefficiency by the staff delivering care, because the solutions may be more linear than squares or circles, which are much more efficient, footstep-reducing designs.

HCD: How much of the best practices for renovations is simply streamlining the way hospitals deliver care?

Becker: In the presentation we’re taking a two-sided approach. There’s a Yin and Yang, and I don’t know if I’m the Yin or the Yang. I’m taking the approach that, for a lot of institutions, I think we’re going to be seeing them looking more seriously at saving their existing facilities rather than being so quick to tear them down, just because of the shortage of resources and the cost associated with it, and because of the changing reimbursements attitude. That’s part of it. There are advantages to keep the existing facility and adapting the existing facility along with new facilities, and that is where my direction in the presentation will be coming from: How do you do that? What do you look for in existing facilities so that you can keep them, rather than right away deciding to tear them down and build a brand new building?

Scherbel: That idea versus how you create the most flexible floor plate to support today’s technology in the most efficient, care-delivery way, which may mean abandoning the old structure and looking for an adaptive re-use for it and looking to create the right floor plate and infrastructure to support care today.

Becker: The discussion of Lean models of healthcare plays into that and the balancing of the goals and objectives of the facility. Every facility is going to have different drivers as to what they want to achieve.

Scherbel: One of the things we’re going to talk about is, What do you measure? How will you measure the success of the project, because we all are what we measure? So if you have different priorities and different goals, you might end up with a different solution because of those priorities. There are influences from the community, care delivery, technology, the changing reimbursement model, and the move toward prevention from intervention.

Becker: We’ve been doing a lot of VA work the past few years and there’s a program called RRTP. They have to first look at existing buildings on their campus to renovate. That’s unique to that client, but that’s one of the mandates of the program.

HCD: How do you feel about modular building as a possible solution to these infrastructure issues?

Scherbel: We’ve done that a couple of times, sometimes for clinics, sometimes for hospital additions.

Becker: We haven’t really thought about it in terms of the presentation, but I think that’s an interesting addition because we actually went through a study for a facility putting in a GI Lab on building new versus building modular.

HCD: If you decide to renovate instead of building new, how do you avoid simply value engineering the original design?

Becker: It really depends on what they want to put into the space. Certain types of buildings and configurations lend themselves better to different occupancies. For instance, if we’re renovating an inpatient wing and we’re going to maintain it as an inpatient wing—going from double rooms to singles—that’s a fairly easy choice on how to do that. If you’re taking that same wing and putting radiology into it, that’s a whole other challenge and where you might have that breakdown. That’s the two sides of it. Looking at the program and what they want to put into an existing building: Do you renovate, build new, or put an addition on to an existing facility so you can get optimal space without having to remove the building? Then it becomes a phasing and operational issue.

Scherbel: Part of that discussion will ask, What are the metrics by which you’re going to judge the final solution? Then you can look at various subtle or substantial compromises you need to make in the design to create ideal solutions. Then you can do an objective analysis of the implementation in the existing structure versus a new one and come up with a value equation to say, “This is the reason why we’ve gone in this direction.”

Becker: We have a project right now that’s three separate floors of a hospital that are being renovated. There are five phases in the project. That was a decision that was made, that they would put up with five phases and three years of interruptions and problems. That was a judgment call: What is the value of keeping that space and operation during those five phases? It was found that due to a lack of land and other things, that was the approach they would take.

HCD: Is the solution ever to construct vertically?

Scherbel: It is, but in our experience, rarely. So many times in my 34-year career, we’ve designed infrastructure to give a structure the capability to expand vertically and with a few exceptions, it’s never done. Because of the complication of coming back into that facility and building over the top of occupied space, it has inherent dangers to it, from a safety perspective, as well as the constant interruption, depending on what departments and occupants are below—for example, if there were patient floors below and you were going through the roof and trying to tie in to structural columns and extend them vertically, and tie in to plumbing stacks; there’s tremendous noise and physical interruptions when you expand vertically. Of course it can be done. Many people put 10-12% in their building to preserve the option to do it later, but most times, the solutions tend to be horizontal rather than vertical.

HCD: What can you suggest to hospitals now so that in the future, they won’t run into these similar infrastructure issues?

Becker: It’s probably the same as it has been for 30 years: design flexibility into your facility and recognize a couple of things; a main one is that you’re going to be outdated and worn out within 20 years—your mechanical, electrical, and plumbing systems, how often do people not plan 30 years out to replace their infrastructure? People are now looking at what to do in 20 years. How do you replace a chiller and air-handling unit? Flexibility is the key thing in new facilities.

Scherbel: Planning the space for expandability and giving an exit strategy to the existing building—or even a new facility—planning the subsequent move so that you can logically expand the building to meet your needs; anticipate the next growth cycle. Our crystal balls are all fuzzy, but we can make logical choices today to allow for, structurally, the building to expand. The next critical piece is the IT infrastructure to support the further integration of electronic records and information, and dissemination of that information throughout the system, which is really going to change the way care is being delivered.

Becker: When we’re renovating buildings today that are 30 to 40 years old, we’re seeing, for the most part, single-use buildings. What you’re seeing in newer facilities is people shying away from single-use buildings. In the past, it was primarily inpatient towers that were built and renovated for different uses. Now, you’re seeing new buildings that are open to what it might be in 20 years.