Large-scale medical centers seek efficiency in design

University of California San Francisco (UCSF) Medical Center at Mission Bay is an 878,000-square-foot building housing UCSF cancer, women’s and children’s hospitals. The $1.5 billion LEED-Gold certified facility opened in February 2015.

Image courtesy of Stantec

While the health care industry is in a building boom of small, off-site facilities, large-scale medical centers are still being delivered. And they're proving that big doesn't necessarily mean imposing or inefficient.

Consolidating substantial specialty care, clinical, research and teaching programs in a single building can require nearly 1 million square feet or more of complex, highly technical space. But large public hospitals, the Department of Veterans Affairs and other major health care organizations are showing that projects of this magnitude can be designed, built and operated efficiently.

What's more, monumental facilities can be welcoming and accessible to patients, visitors and staff.

Inspiring designs

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Photo by Lester Austin/Universe Image

“Parkland proved it can be done,” says Michael Wood, CHFM, CHSP, CHEP, director of engineering, Parkland Health & Hospital System, Dallas. The new 862-bed, $1.3 billion, LEED-Gold certified Parkland hospital has 2.1 million square feet of acute care space. The public hospital, which opened August 2015, replaces a 1950s-era building that had become outdated.

The project was a joint venture by architecture firms HDR and Corgan, both with offices in Dallas. For efficient construction and operations, spaces throughout the building were standardized as much as possible, says Hank Adams, AIA, ACHA, EDAC, director of health care and senior vice president, HDR. Patient rooms, which average 320 square feet, are designed to adapt to different acuity levels. For similar flexibility, the 23 surgical suites and four shelled suites are sized on a 700-square-foot module. Patient room toilets were built off-site for greater economy and quality control, as were the patient room headwalls and the overhead racks housing the mechanical, electrical and plumbing systems. Energy-efficient infrastructure components like fanwall technology and variable-frequency drives were installed to make the hospital more cost-effective and sustainable to operate.

The massing of the building was determined primarily by the colocation of surgical and women’s services. The women’s services program includes 44 labor and delivery rooms (LDRs), nine obstetrics specialty surgical suites and shelled space for four more LDRs. Positioning this department together with the surgery department on the hospital’s third floor created a footprint of 220,000 square feet.

This floor and the floors below it, where the hospital’s diagnostic and treatment block and main public spaces are located, form the base of the building. The patient tower and an adjacent women’s and children’s clinic that extends across the street are stacked at right angles to one another above this base, giving the building a distinctive geometric form. The “structural gymnastics” of this iconic design were driven by the clinical functions of the hospital, explains James J. Atkinson, AIA, LEED AP, EDAC, director of health care planning, HDR.

Adams says the hospital’s late CEO, Ron J. Anderson, M.D., said he wanted the new Parkland to be known in its region as the hospital of first choice. Now, says Wood, “You walk into this building and you’re just in awe about the dignity with which we can serve our patients. It keeps me inspired and my team inspired.”

University of California San Francisco (UCSF) Medical Center at Mission Bay is an 878,000-square-foot building housing UCSF cancer, women’s and children’s hospitals. The Mission Bay campus gave the quaternary care and academic research center an opportunity to expand these services and link them directly to research and teaching facilities already on-site, says Stuart Eckblad, FAIA, executive director, major capital projects, UCSF Health. The $1.5 billion LEED-Gold certified facility opened in February 2015.

According to Eckblad, local height restrictions were a factor in determining the form of the six-story structure, which stretches nearly 800 feet long. The three hospitals, which have a total of 289 beds, are arranged side-by-side in the building chassis, each with its own entrance and elevator core. A public concourse links the three hospitals on the main level of the facility, serving as an organizing element along the entire building. There are a variety of areas for respite, engagement and positive distraction, from the street-level community plaza to the 3.2 acres of rooftop gardens. “You can tell from the design, materials and attention to detail that this is a place where people care,” says Eckblad.

The hospitals’ back-of-house functions are shared for increased operational efficiency and effectiveness, explains Annie Coull, AIA, ACHA, EDAC, San Francisco-based health and wellness sector lead for design firm Stantec. To reduce staff walking distances, a fleet of 27 autonomous mobile robots carries linens, food, specimens and medications throughout the building.

Laurel Harrison, senior principal, Stantec, says the scope of the Mission Bay project gave the project team the opportunity to work with software developers to shape the next generation of programs used to visualize and test building designs. “We were able to push the boundaries of design and construction technology,” she says.

The design and construction team was formed in 2008. “Technology was developing as rapidly as the project,” says Ray Trebino, LEED AP, project executive from the San Francisco office of DPR Construction. According to Trebino, building information modeling was just coming into use in the industry at the start of the project and had recently developed to the point that the entire team, including subcontractors, could work cooperatively on a digital model. Given the size and complexity of the project, an integrated team and collaborative work processes were necessary to ensure that the project reached its full potential, says Trebino.

Renewed purpose

University Medical Center (UMC) New Orleans is a replacement facility for the city’s Charity Hospital, which flooded in the aftermath of Hurricane Katrina in 2005. Charity Hospital was founded in 1736; its 1930s-era building had been expanded to nearly 1 million square feet. At the time of the storm, the hospital had 425 staffed beds, according to Danny Mahaffey, assistant vice president and university architect, facility and property oversight, Louisiana State University (LSU), Baton Rouge.

“When [the community] saw Charity get shut down by Katrina, they were concerned they would never get anything back of that scale,” Mahaffey says. “We fought very hard to make sure that we brought something back that was bigger and better than what they had before.”

The new facility, which opened in August 2015, covers 2.3 million square feet overall, with 1.3 million square feet for health care services, including 446 private inpatient rooms, 60 behavioral health beds, 19 surgical suites, a Level I trauma center and a major ambulatory care component. UMC New Orleans is also a regional medical education center, with academic partners including LSU and Tulane University, and is certified LEED Silver.

The facility was designed as a joint venture by architecture firms NBBJ, headquartered in Seattle, and Blitch/Knevel Architects, New Orleans. Mackenzie Skene, partner, NBBJ, says the project was “a tremendous opportunity to give incredible health care professionals a facility commensurate with the level of care they provide.”

Skene says that due to the size of the building, the design team looked at walking distances differently for this project than they would for a typical hospital. They paid close attention to both vertical and horizontal distances in planning departmental adjacencies and sought to find a “sweet spot” between high-rise and low-rise facility designs, he says. One major driver for the building’s floorplate was the size of the surgery suites, all of which are located on the same floor. The six-story building was designed to be respectful in scale to nearby residential neighborhoods; a low, dense building also is safer in a major storm, Skene adds.

Other storm-protection measures include placing all mission-critical functions at least 21 feet above base flood elevation. Only public and administrative areas are located on the first floor, which is designed so the hospital can continue to operate even if the area floods. An exterior ramp leads to the emergency department (ED) on the second floor.

Health care’s front line

Across the street from UMC New Orleans, a medical center for the Southeast Louisiana Veterans Health Care System (SLVHCS) is under construction, with completion expected mid-2016. The $1 billion, 1.6 million-square-foot project is replacing the New Orleans Veterans Affairs (NOVA) Medical Center facility, which was destroyed, like Charity Hospital, by Hurricane Katrina.

The new medical center will include 200 inpatient beds, 370 outpatient exam rooms and 21 procedural suites, as well as space for emergency care, ambulatory care, mental health services, patient education, transitional care and outpatient rehabilitation. It also will serve as a research and teaching facility. Known as “Project Legacy,” the medical center is designed by Studio NOVA, a joint venture of NBBJ and two New Orleans firms, Eskew+Dumez+Ripple and Rozas Ward Architects. According to the architects, the project is on target to receive LEED Silver certification.

Project Legacy will comprise 12 buildings that each connect to a central concourse. Doug Parris, FAIA, partner, NBBJ, says this layout provides clear wayfinding and shorter walking distances for veterans, many of whom have vision or mobility issues. Because the facility will serve a large region, each major entrance is designed to include services like restrooms and dining for the convenience of people who travel a long distance to reach the campus.

“The primary thing in creating a facility this big is to pay attention to the small things,” says Parris. Purposeful choices in color, furnishings, fabric and similar details bring the design to a human level, he says.

In a strategy also employed at UMC New Orleans, Project Legacy has several courtyards — a traditional New Orleans building feature — that bring natural light into the large structure. The complex is set back from nearby residential areas by greenspace, so as not to appear too overwhelming from the street.

Resiliency measures include a second-floor ED (above base flood elevation) with a ramp that can be used as a boat launch in an emergency. Primary power distribution is located on the fourth floor.

“This medical center is a state-of-the-art facility that will provide hospital care in a region that hasn’t had its own VA hospital in more than 10 years,” says Fernando O. Rivera, FACHE, director and CEO, SLVHCS. “It will be part of the resurgence of medical care and biosciences in this central southern region.”

In Orlando, Fla., another new VA medical center began a phased opening in February 2015. The Orlando VA Medical Center (VAMC) covers 1.2 million square feet “on paper,” notes Steve Langston, AIA, ACHA, EDAC, LEED BD+C, design director for Orlando-based architecture firm RLF. This figure includes a 500,000-square-foot hospital with 134 beds, a 450,000-square-foot multispecialty clinic and 120,000 square feet of community living (120 beds) and administrative space. Add the parking garages, central energy plant and a 6 1/2-foot interstitial space for each floor of the hospital and clinic and the total size of the $600 million project, which is designed for LEED Silver, rises to more than 2.4 million square feet.

The campus is on a peninsula, with the clinic at the front of the complex and the hospital facing the water. Two 1,300-car parking garages are positioned between the two. Langston explains that the site originally was programmed with surface parking using a tram service to shuttle patients to and from parking spaces. However, it was determined that the tram service would be too expensive to operate over the life of the building and the walking distances were too long. Placing the garages between the clinic and hospital, rather than constructing surface parking, reduced the average walking distance from a parking space to either building from 11,000 feet to 250 feet — no tram needed.

The hospital and clinic spaces are connected by a monumental glass, steel and concrete atrium, engraved at the entrance with the words, “For those who served.” The roofline of the atrium swoops across the middle of the medical complex, extending over a central spine where all major circulation in the building occurs. With this organizing structure, “you can get where you need to go easily,” says project executive Bart Bruchok, DBIA, construction and facilities management, office of acquisition, logistics and construction, Department of Veterans Affairs, Orlando. “The designers really tried to think about [patients’] typical transit through the building,” Bruchok says.

Huge undertaking

In an era when smaller, off-campus facilities are getting a large share of attention, major medical centers still play a big role. Educating the next generation of health providers, conducting cutting-edge medical research and providing care for large populations and people with complex medical issues is a huge undertaking. Well-designed, well-built and well-run facilities are helping to bring it down to size.

Amy Eagle is a freelance writer based in Homewood, Ill., who specializes in health care-related topics. She is a regular contributor to Health Facilities Management.

Medical center opens with new purpose after long delay

Grandview Medical Center, Birmingham, Ala., which opened October 2015, includes a 1 million-square-foot, 372-bed acute care hospital and a 220,000-square-foot medical office building.

To create the medical center, Community Health Systems (CHS) Inc., Franklin, Tenn., engaged architecture firm Earl Swensson Associates (ESa) Inc., Nashville, Tenn., and general contractor Brasfield & Gorrie, Birmingham, to repurpose an existing structure that originally was intended to be the world’s first all-digital hospital, to be operated by HealthSouth Corp., also of Birmingham. Brasfield & Gorrie first began construction of the 12-story facility in 2002. That project was halted in 2003. When construction stopped, the majority of the medical center’s footprint was established and most of its mechanical, electrical and plumbing systems were installed and operational, says Brian Willer, AIA, project design manager, ESa. The building sat unoccupied for about a decade.

CHS entered into an agreement to purchase the facility to replace the 50-year-old Trinity Medical Center, located about eight miles from the site. The agreement was contingent on the project’s receiving a certificate of need to relocate the hospital, which was granted in 2013. Keith Granger, president and CEO, Grandview Medical Center, says the health system was thrilled with the visibility and connectivity offered by the Grandview Medical Center site, which is just off a major interstate. “It’s very accessible,” says Andy Collignon, director of facility planning, CHS. The building was also the right size to meet the system’s needs and had well-designed engineering systems, adds Gordon Carlisle, vice president, design and construction, CHS.

The hospital is laid out in what Willer calls a “stacked ancillary” design. “Instead of being spread out, it’s vertical,” he explains. There are 21 elevators in the building. Twelve of these — six for staff, six for patients and visitors — are located in the central core of the building. The remainder are dedicated to certain services. Six elevators, for example, run between the surgery and central sterile processing departments, three for handling dirty items and three for clean items.

Granger says the high-rise structure enabled the hospital to vertically align elevator cores, stairwells, shafts, ductwork and piping, while segregating individual patient conditions on separate floors. One floor, for example, is reserved for intensive care patients. This floor has 48 intensive care beds arranged in three units that can be staffed as needed to meet fluctuating demand. On the surgical floor, there are 30 operating rooms and associated spaces for preoperative and post-anesthesia care, plus five endoscopy procedure rooms.

A 10-level parking deck serves the medical center, with separate parking levels and elevators for staff members and the public. The first, second and fourth levels of the parking deck are aligned with the first, second and fourth levels of the hospital to simplify wayfinding. The public face of the parking deck utilizes the same curtain wall system as the hospital and medical office building, to give the campus a uniform style.

Creating operational synergy through design

McGill University Health Centre’s (MUHC's) Glen site in Montreal, Canada, covers five square blocks. The new 2.4 million-square-foot project consolidated a research institute, a cancer center and three hospitals — Montreal Children’s Hospital, the Royal Victoria Hospital and the Montreal Chest Institute — into a single facility with 500 beds. There are 346 beds for adults and 154 beds for pediatric patients.

Prior to the Glen site’s opening last year, the Royal Victoria Hospital was operating out of a building that dated, in part, to its original 1893 construction. “Delivering quaternary and tertiary care in that facility was very challenging,” says Imma Franco, director of technical services, planning and real estate management, MUHC. The new building is designed for improved clinical operations and infrastructure. MUHC reports that the LEED Silver facility will use 35 percent less energy than other Canadian hospitals.

The facility is the result of a public-private partnership. It was financed, designed and will be operated for the next 30 years by a consortium headed by engineering firm SNC-Lavalin, Montreal.

The design preserves the history of each constituent institution while allowing them to work together to maximize human resources, financial resources and equipment, Franco says. Combining hospital, research and cancer programs at a single site allows them to share clinical and nonclinical support services. For instance, there is now one main cafeteria — a congenial space with abundant natural light that has become a gathering place for principal investigators and other staff, according to Franco. Spaces like this that encourage interaction between colleagues at the facility are creating synergy among the programs, she says.

Much of the building’s square footage was driven by an effort to provide the best possible patient experience. The project team would compromise on administrative areas at times, but held firm on the size of patient rooms, operating rooms and exam rooms, Franco says. The team was sensitive to how the scale of the building could impact patients, and design changes were made where possible to reduce walking distances. “Although it’s big, I think we were successful in optimizing adjacencies,” says Franco.

Circulation routes for patients and visitors are designed to be straightforward. Single corridors lead to three large atria that fill the building with natural light. Eleven major pieces of public art serve as wayfinding cues inside and outside the facility. Curved blocks marking the main entrances provide a welcoming first impression and integrate the medical center into the urban fabric of its neighborhood.

To learn more about why these organizations are building big in an era of small facilities, read our exclusive interviews with their executives.