Stand-alone health care buildings
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.
CSE: Please describe a recent stand-alone medical building or specialized treatment facility project you’ve worked on.
Calhoun: We recently designed a freestanding emergency department in Texas with a packaged rooftop variable air volume (VAV) air handling unit (AHU) having hot-water reheat in combination with a variable refrigerant flow (VRF) system to serve back-of-house spaces. These are prototype buildings with a collaborative effort in evolving the prototype design. The prototype team consists of two architectural firms and three engineering firms. The primary objective of the team is to standardize the building design to increase speed to market as well as to enable bulk-purchasing agreements, because the owner intends to build many of these in the upcoming months.
Kos: We recently developed a project with a local health system for the construction of a stand-alone facility in the western suburbs of Chicago. The building is single-story and serves multiple functions. The facility systems support an imaging suite, physical therapy treatment area, and multiple clinical specialties with an immediate-care component. The building is a medical office, business occupancy, so one of the largest design issues was balancing the health care provider’s performance expectations of mechanical and electrical systems with the developer-driven cost model of an office building. Hospital systems are typically more familiar with more robust systems with higher levels of redundancy, filtration, and requirements for air-change rates and pressurization control. We had multiple conversations with the facilities and infection-control teams to understand the requirements for the clinical procedures and process that were planned as well as educating them on the proposed systems.
Boothe: We recently completed a freestanding emergency department and medical office building (MOB) in Naples, Fla., for Naples Community Hospital. The 1st-floor space provides emergency department access to a growing population closer to their homes. The 2nd floor provides convenient primary care doctor access to this same population group. The 1st floor also includes imaging (magnetic resonance imaging [MRI], computerized tomography [CT] scanning, and radiology) to support the emergency department.
Kolm: We worked on the Methodist Health System Women’s Hospital and Medical Office Building in Omaha, Neb. This is a hospital and stand-alone MOB; the 94,000-sq-ft freestanding MOB is home to physicians in all areas of women’s health. The physicians provide care in the areas of obstetrics, gynecology, menopause management, urogynecology, and pelvic health, to name a few, and includes an outpatient lab and imaging services such as CT, MRI, mammography, and ultrasound. The majority of the mechanical system was designed with a standard hot-water boiler for VAV reheat with direct-expansion (DX) cooling and gas-heated rooftop units serving the VAV system. Although one specific area of special consideration was for the space where in vitro fertilization is performed. For this particular space, care had to be taken for system vibration and reliable temperature and humidity control to increase the chance of successful procedures for patients.
CSE: Describe your experience working with the contractor, architect, owner, or other team members in creating a BIM model for such a project.
Kos: When it comes to BIM projects, we typically work backward from the expectations for the final deliverable. It is most important to understand how the project owner intends to use the final modeling. In some cases, the owner is sophisticated enough to use the model for operations, while others use the BIM and modeling process for a higher level of coordination and to facilitate construction. When the final deliverable is determined, the team can lay out an implementation plan. The plan is aligned with the owner, design team, and contracting team on the process, deliverables, and the maintenance of the models through the life of the project. The biggest issue we have encountered in BIM modeling is the misalignment of expectations with standard deliverables. . At midproject, when the design models are transferred to the contractor, and the contractor originally thought they could start construction upon the transfer. It can also happen at the end of a project, when the facilities staff doesn’t use the deliverable as expected.
Boothe: For our recently completed freestanding emergency department and MOB project, design was completed in Autodesk Revit. All major MEP systems were modeled in 3-D to help better coordinate the above-ceiling spaces. While coordination drawings were still produced by the contractors, they used the drawing files from the MEP design to create these drawings, help speed this process, and help ensure the installed systems closely matched the design intent.
Kolm: BIM is a standard deliverable providing the best opportunities to coordinate with all other disciplines. Combining multiple advanced BIM tools allows the owner and contractor important design input during the early design phase of the project. Parametric modeling combines the benefits of multiple BIM platforms to complete on-the-fly energy and cost modeling, allowing the owner to make informed decisions regarding construction and operational costs prior to a completed design. Variables that can quickly be implemented include building orientation, glass type, amount of visible versus spandrel glass, insulation types, daylighting, light shelves, etc. Input from the contractor regarding constructibility and input from the owner regarding building features can be evaluated quickly using parametric modeling software.
Haynes: BIM is a tool that is so powerful that we have yet to realize its full potential. We’ve been able to create and coordinate models with no conflicts that have resulted in zero change order projects. Contractors can use the model content to directly export into their shop material software to instantly create takeoffs, estimates, and shop drawings. We can even embed operations and maintenance (O&M) data for every piece of equipment for a facility and then physically tag that equipment with a QR code, so that maintenance staff can use a tablet to scan the equipment in the field and access all the data: submittals, plans, O&M manuals, direct link to the building automation system graphics, etc.
Calhoun: The use of Revit in our project work is very common after 10 years using modeling software. Our clients and contracting partners are very adept at transferring information through the models, and this makes for seamless information transfer throughout the design phases. On a recent project, the project team worked together to create a fully coordinated above-ceiling 3-D model that was released to a vendor to prefabricate corridor ceiling racks. The intent is for these racks to be repeatable to increase speed to market and reduce onsite labor.
CSE: Describe a recent retrofit of a stand-alone medical building or specialized treatment facility. What were the challenges and solutions?
Boothe: We recently renovated an outpatient surgery center that the owner had not used in 2 or 3 years. As a result, they had not renewed the facility’s license. Due to the facility’s age and changes in codes over the years, there were many issues, such as operating room (OR) size, clearances in holding/post-anesthesia care unit, electrical circuiting, laminar flow arrangement in the ORs, etc., that had to be brought up to current code standards. We sometimes take for granted how quickly standards/codes change from year to year for medical facilities. This issue greatly complicated the complexity and scope of the project.
Kos: As the "retailization" of health care continues, clinical occupancies are moving into sites that are traditionally designed for retail purposes. One of the more challenging issues with the mechanical systems that are typically sized and designed for large, open retail spaces is adapting them for use in a space with multiple offices, exam rooms, and other clinical uses. The retail envelope and systems also are typically designed for a more transient occupant and at the lowest cost.
One of our recent retail-to-health care redevelopment projects was reporting heating issues and cold spaces. After studying the building and the systems, it was determined that the building was experiencing significant infiltration issues and remediation was required to address direct paths of air into the building. Some of these issues go unnoticed until a new mechanical system is introduced or until the population is more stationary and the clientele is pediatric, geriatric, or ill.
CSE: Have you designed any stand-alone medical buildings and specialized treatment facilities using the integrated project delivery (IPD) method? If so, describe one.
Haynes: What I have found is that not everyone has the same definition of IPD. I have done several projects that are "IPD-lite," meaning that they lend themselves to follow some structure of the IPD process, but without fully integrating the project under one contract. I’m currently in the middle of my first "lean IPD" as a design-build partner to the mechanical contractor. It’s a different mentality altogether. The key to the process is to have the right team members. You have to all get along and like what you do, or it will fail.
Calhoun: We have not seen IPD or design-assist trends extend into this market. The majority of these types of facilities are construction management at-risk or traditional design-bid-build.
CSE: What unusual requirements do stand-alone emergency rooms have from an engineering standpoint?
Boothe: One need of a freestanding emergency department (ED) is to ensure that the facility remains operational during power outages. For our recently completed freestanding ED in Naples, Fla., this meant that a majority of all equipment was powered from the emergency generator. This includes large loads such as all air conditioning systems and imaging loads such as the MRI and CT scanning equipment. In this case, our freestanding ED was approximately 20,000 sq ft in size but included an emergency generator of 500 kW. This is a higher ratio of emergency power to building area as compared with a full hospital, as there is more load diversity in these larger buildings.
Calhoun: In most states, licensed FSEDs have code requirements similar to those of an emergency department in a hospital. The operational and clinical requirements are essentially the same as those in a hospital ED. Unique engineering challenges are presented, in part, by the fact that the requirements must be met by stand-alone systems as opposed to large central-plant systems. The MEP budget challenges associated with meeting stringent requirements with separate systems are probably even greater in this type of facility—with a major focus being on finishes and marketability, which does not typically allow for a larger percentage of budget allocated to MEP.
Kos: First and foremost, we must consider the level of acuity of the patient to ensure our commitment to patient well-being and safety. Is there a possibility of patients with infectious diseases? Is the potential for a patient to be in a state that renders him or her incapable of self-preservation? Second, we must review the care to be provided. Will there be MRIs, CTs, X-rays, invasive procedures, blood labs, and/or pharmacies? Will any general anesthesia be administered? Will this be a Category 1, 2, 3, or 4 facility? Finally, we must apply the appropriate codes and standards. The design of health care facilities is governed by many regulations and technical requirements. The answers to the first two questions will inform what codes to apply and what level of infrastructure is required.
CSE: When a building is occupied by several specialty medical services, describe the various methods you use to ensure each suite/office is designed successfully.
Bryan Laginess: Separating the systems as much as possible is ideal, but not always cost-effective, and can make flexibility of the building difficult. The methods for designing will vary greatly depending on the building—old versus new, the developer-independent versus health-system-owned, and the exact specialty occupying the building. Submetering services, separating HVAC distribution, and separating emergency power distribution has a greater need when the specialties in the building are drastically different. Consider a dialysis or surgery suite in the same building as a family practice office.
Calhoun: Some systems may be required by some state codes to be independent, depending on the licensing of each specialty suite. These systems may include HVAC, essential electrical, nurse call, fire alarm, and medical gas. Regardless of any code requirements for separation, independent HVAC systems for any suites with special filtration or temperature/humidity requirements will help ensure proper conditions for critical spaces without incurring unnecessary first costs or energy costs for the typical MOB suites. For example, on a recent project, zone-level temperature control was provided to give tightened control for different space use. A VRF fan coil system was used for more critical spaces due to the redundancy it provides, allowing for simultaneous heating and cooling while limiting the number of condensing units and allowing for longer refrigerant line length to optimize the grouping of the outdoor condensing units.
Kos: Many times the answer to this question is dictated by the building. Is it a new building? Is it developer-driven? Is it owned by the tenant? It is important to align performance expectations at the onset of the project. Will the building have any specialty equipment requiring special infrastructure? Are there any procedures that will require an onsite emergency generator? Medical gases? Nurse call? Specialty ventilation? Is there an opportunity for systems to be shared between tenants? Each project has unique characteristics. We collaborate with the owner and architect to maximize opportunities of shared systems while providing the owner with a solution that is fit-for-purpose and fit-for-future through redundant, flexible, and adaptable design.
CSE: Describe a Level I (highest level) trauma center you’ve designed. What demands were placed on the mechanical, electrical, plumbing (MEP), fire protection, lighting, etc. engineering team?
Calhoun: All of the Level 1 trauma centers we have designed have been part of a larger hospital and not a stand-alone specialty center.
Kolm: The philosophy regarding a polytrauma room design for a U.S. Department of Veterans Affairs facility was to address the needs of soldiers with multiple injuries. The room was much larger than most, with infrastructure flexibility necessary to accommodate multiple specialists upon patient evaluation. Usually, a room design will have patient, work, and family zones. A polytrauma room has much more space for clinicians and roll-in equipment based on the treatment. Close interaction and coordination with the large clinician staff are necessary to accommodate the purpose of the room to care for the unfortunate multiple injuries of war.