Stand-alone health care buildings
Stand-alone medical buildings and specialized treatment facilities are engineering challenges, and more are being designed and built due to changes in health care requirements.
Neal Boothe, PE, Principal, exp, Maitland, Fla.
Douglas T. Calhoun, PE, Senior Vice President, WSP | Parsons Brinckerhoff (formerly ccrd), Dallas
Caleb Haynes, PE, Principal/Director, TME LLC, Birmingham, Ala.
Brian Kolm, PE, Team Leader, Mechanical, HDR Inc., Omaha, Neb.
Craig Kos, PE, LEED AP, Vice President, Environmental Systems Design Inc., Chicago
Bryan Laginess, PE, LEED AP, Vice President, Peter Basso Associates, Troy, Mich.
CSE: What's the No. 1 trend you see today in the design of stand-alone medical buildings and specialized treatment facilities?
Neal Boothe: The biggest trend we are seeing is simply the larger demand for these facilities. As hospitals fight to expand their customer bases, we are seeing more of these facilities. They have become a way for hospitals to reach out much further into their surrounding communities to attract patients. Also, the use of these stand-alone facilities can help reduce crowding to hospital areas, such as their emergency departments, imaging departments, surgical departments, etc., by giving patients another location to visit for medical care.
Douglas T. Calhoun: The use of prototypical designs to maximize speed to market. Prototype designs can include prefabricated headwalls, restroom "wet walls," or even entire rooms to save time in construction. Prototype designs have always been difficult to accomplish in the health care industry due to changing patient populations, specialty services, etc., but the stand-alone medical buildings and specialized treatment facilities are focused on a specific patient population and can be built in any region to attract that population. Typically, the only changes required are driven by differences in state or local codes, and those rarely affect the experience for the patients.
Caleb Haynes: It shouldn't be a surprise to anyone working in health care today to see the emphasis that is being applied to minimizing first cost. With escalating cost structures and severely depressed margins, all health care organizations are looking for ways to minimize spending and get the most return on their investment. Creative project-delivery methods that minimize waste and maximize capital have become an increasing trend in the market. Integrated project delivery, design-build, and lean process management have forced engineers out of their design-bid-build comfort zone and into a new and efficient project-delivery process.
Brian Kolm: With regard to lighting design, energy codes are more achievable using LED lighting technology, simply based on the lower energy requirements of LED versus fluorescent fixtures. But with owners driving lower energy costs and the expectation that codes and standards will respond to LEDs with lower lighting watts per square foot, the lighting designer becomes an essential team member. A lighting designer's resume requires the aptitude to meet both the architectural and energy needs of all spaces that serve patients and the public alike. Using a lighting designer with software experience and strong working relationships with architects and owners is the key to success.
Craig Kos: Most stand-alone medical facilities designed recently are affiliated with a health care system. They are being used not only as a location to provide distributed care on an outpatient basis, but also as a feeder system for the parent hospital. To this end, branding has become important. This branding often dictates certain design standards must be applied to the facility. These standards can cover a multitude of mechanical, electrical, plumbing (MEP), and technology systems and often have not been refined to meet an outpatient facility pro forma. Health care is under tremendous pressure to reduce costs while being more responsive to the needs of the patients. It is contingent on the design professional to work with all parties concerned to develop an infrastructure that meets the intent of the standards but still fits the allocated resources.
CSE: What other trends should engineers be aware of for stand-alone medical buildings and specialized treatment facilities in the future (2 to 5 years)?
Kolm: Technology integration is key—the design is associated with the patient experience as it applies to technology as well as architecture. There are several considerations:
- Providing a system that allows health care providers to safely share patient digital information between doctors onsite or to remote specialists is a minimum requirement.
- Digitally connecting patients to room temperature, menus, movies, and education will be a patient expectation.
- Digitally tracking patients, staff, and equipment for the purpose of data analytics is being adopted; the granularity of locating is currently being evaluated.
As engineers, we need to understand the goals and confirm that the owner has thought of all the possible scenarios, and then provide infrastructure and equipment with flexibility for the future in mind.
Haynes: The biggest trend is the increased focus on patient comfort and satisfaction. With the major shift to a value-based reimbursement model and up to 2% of Centers for Medicare & Medicaid Services (CMS) reimbursement being at risk and tied to patient satisfaction, the facility design is more important than ever. Design trends that support this include designing for total patient comfort control, simulating spaces through virtual reality (VR), smart hospitals, increased focus on hospitality-based environments, etc. There also has been a big increase in research and patient surveys in evidence-based design to guide us in design decisions.
Calhoun: It is also becoming more common for hospitals to operate stand-alone facilities as a part of the hospital. For example, an emergency clinic within a business occupancy may be operated by the hospital, therefore, it's not licensed as a freestanding emergency department (FSED) in some states. While this approach can reduce costs due to reducing compliance requirements that would apply to a licensed facility, the entire team should evaluate the criteria that will be followed considering standard of care as well as any potential change in ownership in the future. We are now seeing a trend to expand services of these stand-alone medical buildings into "microhospitals." The market share and reimbursements are increased greatly by constructing licensed facilities to include a few 24-hour beds and two or three operating rooms (ORs). In most states, this is viewed as a full hospital under the licensing regulations and requires departments such as dietary, lab, and pharmacy. This trend only increases the challenges of building to a clinic budget range with a very aggressive schedule.
Kos: How do we design spaces used for telehealth, ambulatory care, preventive health, immediate care, dialysis centers, cancer centers, surgery centers, and heart centers? How do we help our client understand the appropriate language to put in leases to ensure they are provided with the proper infrastructure? As part of the increasing cost pressures, health care providers are needing to compete not only for patients but for staff as well. New regulations place a higher emphasis on electronic medical records, accessibility, and physical and electronic security. As more care modalities are transferred from hospitals to outpatient facilities, buildings must be more adaptable to change. System-performance expectations/requirements vary greatly for different modalities.
Boothe: Self-sufficiency is important; in the freestanding emergency department we just completed, the owner needs to maintain the building indefinitely throughout a disaster. This is especially relevant because this building is located in South Florida and susceptible to hurricanes. The entire building was designed to impact-resistance standards. Also, the amount of emergency power needed was significant for a "small" 20,000-sq-ft footprint. All air conditioning was put on emergency power in addition to all imaging equipment, along with a significant amount of equipment, general power, and lighting.