The owner of Palomar Medical Center (PMC)—a 10-years-in-the-making, new-build project that cost just under $1 billion—has never been shy about its ambitions. When Escondido, Calif.-based Palomar Health (PH) realized that the state’s seismic upgrade requirements would have been cost-prohibitive to implement in the old PMC building, CEO Michael Covert took the opportunity to build not only a new facility, but a new organization.

“This was a chance to really look at evidence-based research and incorporate as many of the advances as we could find,” says Dr. David Tam, chief administrative officer of PH’s Pomerado Hospital and head of facilities maintenance and construction for the entire organization. “Michael’s goal was to build a new, technologically advanced hospital that would require our employees to reinvent how we deliver healthcare for the 21st century.”

The process of building the “hospital of the future” started with standard industry buzzwords—building information modeling (BIM), integrated project delivery (IPD), evidence-based design (EBD), and sustainability—that were then cranked to 11 on a massive scale. PH partnered with CO Architects (Los Angeles) and the San Diego office of DPR Construction, among others, to get the job done on this 288-bed, 740,000-square-foot hospital, which opened for business in August 2012. 


Banking on BIM
The timing of the PMC project, says Tom Chessum, principal, CO Architects, “corresponded really well to the timing of BIM coming to a level of maturity where we could actually support a model of that size. The more we got into the capabilities of what BIM could offer in terms of efficiencies throughout construction, the more it seemed obvious to move to integrated project delivery.”

Though the PMC project team used a construction management multi-prime delivery method with separate contracts between PH and both the builder and designer, those contracts included provisions that function in an IPD fashion regarding relationship, risk, and incentives. Tam asserts, “It was the only way to go, in order to have the flexibility to make changes and have the entire construction and design team fully engaged.”

Operating with a budget of $956 million, the project team’s goal was to file for a temporary certificate of occupancy on April 9, 2012, with heads in beds on Aug.19. PH informed the project leaders that if PMC finished on time and on budget, the owner would split any contingency with everyone from the architect to the electrical contractor to the drywall and steel folks.

BIM was critical to the success of meeting that goal. Tam shares an example of how, after many meetings with the foremen out in the field, he learned that one of their biggest challenges was dealing with the time it took to get requests for information (RFI) through all the right channels. “So if they had a problem where a pipe didn’t look like it would fit, it took forever to get an RFI to the trailers, to the engineers and architects, then to the owner, and then all the way back down,” he explains.

The solution was to trick out a construction site job box with a computer, printer, and wireless, which key people would accompany out into the field on days when work was being done on decision-intensive, construction-intensive areas.

“So when the foreman says, ‘This pipe is going to interfere with that,’ we could take a look at it on the BIM model, realize he’s right, and then huddle together: ‘How do we correct that? Plumbers, what do you think? Electrical? Inspector of record, would you be OK if we did XYZ?’ And then we could print out the new spec right there,” Tam says.

Using BIM in this manner—allowing what would typically be a weeks-long turnaround to be settled in a couple of hours—“saved us a huge amount of time, and it created significant trust with the trades in the field,” Tam says. “That kind of trust-building helps everyone be more willing to take a little risk.” Chessum agrees: “Everybody knows what everybody is doing. All the good things that happened, for the most part, they all happened thanks to trust and teamwork.”


Understanding the evidence
When considering evidence-based design principles and how best to deliver them on the PMC project, the team allowed a similar sense of collaboration to inform decisions. From the beginning, PH wanted to incorporate a number of proven applications of EBD, and then some.

“I think at the time there were 28 different evidence-based practices that this project was going to go after full scale,” Chessum says. “Beyond that, some additional items were ‘inventoried,’ so that even when it wasn’t possible to fully implement them right away, the ability to operationalize them later was there.”

“Champion teams” were formed to stay on top of each identified best practice, delving into the research and advising on the design from conception through occupancy.

One striking example of EBD in practice at PMC is the prevalence of natural light—and not just on the patient floors—via enormous low-emissivity windows supported through a steel structural reinforcement system (so no X-beams to block the light or view). Light wells carry daylight into the deepest recesses of the interventional services floor, and outdoor courtyards are visible even from the operating room cores.

Tam points to research that suggests that workers exposed to natural light, and to the diurnal rhythm of night and day, make fewer mistakes. When the workers in question are hospital staff in an OR, that’s a statistic worth considering. “In a large surgical floor or interventional platform, there are people who might work 12-hour shifts and never see daylight,” Chessum says. “Even if they’re walking down the corridor, to be able to walk by a courtyard that’s full of green things, you can say that reduces stress and increases focus.”


The roots of green thinking  
Access and views to green spaces go way beyond the sterile OR core. The PMC design and construction team took sustainability issues as much to heart as it did EBD and IPD, and the most obvious feature to showcase this is the undulating, 1.5-acre green roof over the diagnostics and therapeutics wing.

“Any green roof has a sustainability impact related to reduction of heat island effects on roofs, dealing with rainwater, and things like that in terms of filtration,” Chessum says, “but that was only one part of it.” In fact, the green roof actually grew out of a different sustainability (and cost) concern regarding future renovations within the space.

Tam explains that the hospital areas most prone to requiring clinical upgrades are ORs, radiology departments, cath labs, and the like. So the diagnostics and therapeutic wing was purposely designed to be separate from the nursing tower so as not to disrupt inpatients and public spaces in the hospital during future construction projects.

Then, Tam says, the sustainability team asked the engineers, “‘What’s the costliest thing about renovating these kinds of technically intensive spaces?’ Their answer was, ‘Having to blow through all the vertical columns that hold the HVAC, IT wiring, and plumbing.’” In response, CO Architects designed a wavy roof over the entire wing, incorporating 30-foot-high spaces that allow all those mechanicals to reside in th
e ceilings.

And that’s when the green roof came into play. “The sustainability team said, ‘OK, we have two football fields worth of wavy roof, which is going to create a lot of sun radiation hitting that roof and reflecting into the nursing tower,’” Tam continues. “And that would cause an increase in energy consumption in order to cool the tower.” Voilà: Soil was dispersed and native flora planted everywhere, reducing the solar radiation by almost 30%. “We estimate that’s about

$1 million-$1.5 million in energy saved,” he concludes. The vast, green space—conveniently reminiscent of the rolling hills of Escondido—also provides more natural views for patients and staff alike.


Embracing the future
Inside the new facility, technological updates abound, including an advanced medical-grade wired and wireless network, monitoring devices that patients wear so doctors can view them from the field, and multiple customized communication tools for caregivers. This means that the staff not only has to figure out how to navigate the new space, but adapt to a huge cultural shift in the way they do their jobs.

As that process continues, and the PMC team puts together its plans for post-occupancy evaluations, Chessum offers his favorite aspect of the project. “On one hand, you have the highest level of technology and equipment, and the whole complexity that goes with that. And on the other hand, you have the day-to-day need we all share to see the sun, to see a tree, to notice that the wind is blowing just a bit. To me, that’s the ultimate juxtaposition of what healthcare is all about: finding that balance in these kinds of buildings.”  

For more information on Palomar Medical Center, please visit Kristin D. Zeit can be reached at

Project summary

Completion date: August 2012

Owner: Palomar Health

Architecture: CO Architects

Associate architect for D&T medical planning: Stantec

Interior design: Stantec; RTKL

Contracting: Multi-prime with integrated delivery provisions

Engineering: KPFF Consulting Engineers (Structural/Civic); ME Engineers (MEP)

Landscape architect: Spurlock Poirier

Lighting designer: Horton Lees Brogden Lighting Design

Construction management: DPR

Photography: Tom Bonner

Central plant: 32,812 gross sq. ft.; $62.5 million; $1,905/sq. ft.

Site development: 771,842 sq. ft.; $31.4 million; $41/sq. ft.

Total building area: 740,000 sq. ft.

Total project cost (including land): $956 million

Total construction cost: $562 million

Cost/sq. ft.: $760