Feeling the impact of healthcare reform and the recession, many hospital owners are faced with the difficult task of driving down costs, which can include choosing between building new facilities or renovating existing ones. Requiring large capital expenditures and longer timelines, the design and construction of new hospitals isn’t always a viable solution. Consequently,the decision to retrofit and update existing facilities has become more popular, because it allows hospital owners to meet changing needs and increasing demand with a smaller price tag and shorter schedule.

In fact, renovations come with a number of advantages. For example, existing, underutilized space can be repurposed to avoid the cost of new infrastructure. Hospital owners also have the opportunity to review current operations and provide input into a new design that modernizes the facility in a way that delivers the highest quality of care at a lower cost than new construction. Most importantly, this option allows existing patient care to continue as upgrades are performed.

While there are several benefits for hospital owners opting to renovate existing facilities, there are unique challenges associated with a renovation, as well. The greatest challenge often is achieving uninterrupted hospital functionality, which requires the construction site, traffic, and personnel to remain isolated from patients, visitors, and staff. Even if the larger facility remains operational, some portions may need to be closed or removed from use in order to allow for the construction of infection control barriers.

Renovation work also presents the unique challenge of bridging new components to existing systems. It’s critical that utility services such as medical gas, plumbing, HVAC, electrical, and fire and life safety systems are not interrupted. In addition, the demand for electronic medical records has created a constraint on existing IT infrastructure, meaning many hospitals are looking for creative ways to increase IT capacity without adding infrastructure.

Early involvement

To overcome these challenges, owners have embraced more progressive methods, such as design-build. Design-build delivery for renovation work yields benefits that are not available with traditional project delivery methods, such as design-bid-build or plan-and-spec. Too often, traditional delivery methods lead to siloed workflows that create conflicts and costly change orders.

On the other hand, design-build enables coordination prior to the start of construction, which can drive down the cost and accelerate the schedule for construction. By involving the general contractor and trade partners during the design phase of a project, teams can provide a detailed, early site investigation that offers insight into the location and condition of existing systems. By collecting information early on that otherwise would be discovered during construction, teams can develop plans to address the issue and avoid change orders and schedule delays. Additionally, the benefits of innovative technologies, such as building information modeling (BIM) or laser scanning, are more tangible under a design-build approach. Design-build, coupled with BIM and laser scanning, helps avoid errors associated with outdated or inaccurate as-built drawings.

Design-build at Sharp Chula Vista

Design-build teams engaged during the procurement and design portion of a project can also lead to solutions that yield a greater return on investment. For example, the Sharp Chula Vista emergency department expansion project successfully used this approach. The 10,000-square-foot project consisted of 5,000 square feet of renovation and 5,000 square feet of expansion beneath an existing labor and delivery floor. While the project was released for bid with a set of bridging documents, the design-build team, as part of the proposal process, developed a new layout that differed significantly from the original design. This new layout improved operational flow within the emergency department, decreased the number of project phases from three to two, and reduced the project schedule by nine months. The redesign allowed the team to increase the bed count from 22 to 44 beds without expanding the size of the new construction area. Maintaining bed count was necessary because the department operated at full capacity and is one of the busiest emergency departments in San Diego County.

In addition, the collaborative approach extended to the design phase, as teams utilized a Lean construction approach called pull planning. During pull planning the entire design team worked with the owner to develop the design schedule. By using the target submittal date set by the Office of Statewide Healthcare Planning and Development (OSHPD) and working backwards, the team collaboratively determined when and how information had to be transferred between team members and when design decisions had to be made in order to support this accelerated design schedule. By developing clear expectations of each deliverable, team members were able to meet the schedule and deliver exactly what was needed, while avoiding extra work or rework later during the design phase. For example the owner shared which users would be reviewing each design submittal and what information they would be looking for to ensure the right information was added to the drawing at the right time. This guaranteed that a highly coordinated 3-D package could be developed for submission to the OSHPD in only four months. When compared to the owner’s original design schedule of six months, this reduced the design phase by 30 percent.

By engaging contractors earlier in the lifecycle of the project, the design team was able to develop additional construction approaches, including temporary egress paths and infection control barrier plans. Reviewing these plans with the appropriate authorities, along with incorporating the solutions into the design package, eliminated the risk of potential conflicts later in the construction process.

The benefits of the design-build approach were present throughout the construction phase, too. The team was able to use the knowledge gained during the early site investigation to minimize the disruptions associated with utility shutdowns. The construction required relocation of existing plumbing systems that serve the labor and delivery department directly above the emergency department. The site investigation helped the team to identify the services that required relocation as well as tie-in points to new services, which allowed the system to be disconnected and reconnected to the new services without any shutdown to that department. By involving the medical gas provider during design, the team developed a plan to backfeed medical gas to the facility, allowing the construction team to increase the main oxygen distribution line to the emergency department without disruption to hospital operations.

Rethinking strategy

Renovations offer a long-term solution to upgrading healthcare facilities, and a collaborative design and construction team can overcome the innate challenges associated with projects taking place within an operational healthcare environment. By using a design-build delivery method for these types of projects, owners benefit from a team that has early involvement and ownership of the project. This helps to ensure that all challenges are identified early in the process and solutions are developed to meet the needs of the facility. As owners rethink their capital improvement strategy, they can work with a design-build team to identify innovative solutions that add value during the project lifecycle, while still meeting budget.


Katherine Blume, PE, LEED AP, is project director at Southland Industries (Garden Grov
e, Calif.).
She can be reached at kblume@southlandind.com