2020 Hospital Construction Survey

Architects who began designing Piedmont Tower in Atlanta in 2016 knew the project would have to move swiftly to meet the target goal of opening by the end of 2020.

The $600 million medical tower is a massive undertaking that will add a cardiovascular care center, more than 400 beds and 13 operating rooms to Piedmont Atlanta Hospital. Designers planned to build the entire structure and up-fit 10 floors of the 16-floor tower, including the cardiovascular center, and then complete one floor per year after that. 

To accelerate the project, HKS Architects, Chicago, is relying heavily on building information modeling (BIM) and cloud-based collaboration that allows designers, contractors and engineers to coordinate the project in real time and eliminate the need to exchange design models, among other time-savers.

As of early this year, the project is on budget and on schedule to open in late 2020. 

“From a design standpoint, BIM is a continually important tool,” says Joe Sprague, FAIA, FACHA, FHFI, senior vice president and principal at HKS Architects, Dallas, and a member of the American Society for Health Care Engineering (ASHE) Board. “Along with allowing the team to coordinate throughout the entire project, BIM provides 3D, real-time visualization and allows for input of critical project data. I continue to believe that CAD is also very important in that regard.”

Technology like BIM not only helps hospitals save time and money, it offers a cohesiveness that designers even two decades ago could not have imagined. 

“BIM is surging in use partly because it’s hard not to have BIM in your system,” says Brad Pollitt, AIA, vice president of facilities at UF Health, Gainesville, Fla. “BIM is great for clash detection, enhanced collaboration and easier decision making. It’s becoming necessary for most hospital projects.”

BIM is just one of the advanced technologies hospitals are relying on to guide the design and construction process from conception to realization, according to the 2020 Hospital Construction Survey conducted by ASHE’s Health Facilities Management magazine. 

The survey, which included responses from more than 400 facilities professionals at hospitals across the country, asked a wide range of questions on everything from design trends and budgets to certification and commissioning. 

For the first time, the survey asked respondents which advanced technologies they have used on construction projects in their health care organizations. 

Benefits across the board

Along with BIM, prefabrication, 3D projection mapping, modular construction and 360-degree photography are among the most-cited technologies for design and construction projects, according to the survey. Most cited benefits are cost control (80%), enhanced communication (53%) and staying on or ahead of schedule (52%), which is in line with what is happening throughout the field, according to Mark Nichols, AIA, ACHA, LEED AP, principal at Eckenhoff Saunders, Chicago.

“Each of these technologies is different, but they all support one another. And in a sense, they all have a data component,” Nichols says. “Hospitals using these technologies are seeing lower costs, faster results and better coordination of documentation, leading to better outcomes all around.”

In the survey, respondents were asked open-ended questions about technology-driven projects and offered comments, including:

• “We have used virtual reality, 3D imaging, light detection and ranging (LIDAR), and BIM 360. So far, all have saved time and reduced changes.”
• “BIM, prefabrication and 3D projection mapping were used in our construction of a full replacement hospital.”

After BIM, prefabrication — building or manufacturing parts of a project at a location other than the job site — was the second most cited advanced technology by survey respondents. While it is not a new construction tool, technology is amplifying the benefits of prefabrication. 

Said one respondent: “Using prefab bathrooms has become a standard in our organization. It saves a great deal of time.”

Modular structures — those constructed in a factory and transported assembled on-site — continue to grow in popularity and are especially beneficial for larger hospitals, says Pollitt. “For something like bathroom design, you can build hundreds of these a year and stockpile them, which saves time and costs. But it wouldn’t be as effective for a 200-bed hospital. You would have to get in front of the design team to standardize all the elements from the beginning.”

Pollitt says some health care providers in Florida are using modular structures “as big as a semi-truck” to build freestanding emergency rooms. 

Said one survey respondent: “Exterior wall panels were constructed at a factory, shipped to the site and assembled in record time with less labor. Cost and time savings benefit.”

Though not yet in widespread use, more designers are relying on augmented reality, which layers computer-generated enhancements over an existing reality; and virtual reality, a computer-generated simulation or recreation of a real-life environment.

McCarthy Building Companies Inc., St. Louis, is using 3D technology and augmented reality to create a real-world experience for clients, says Alex Belkofer, director of virtual design and construction at McCarthy. 

“We are doing virtual mockups for health care clients and walking them through the project using a 3D model, or doing it live on the job site,” Belkofer says. “The feedback we are getting is great. Health care clients say the technology creates an environment that feels real and gives them a feeling of comfort. It gives the health care owner confidence about the project and really helps with buy-in.”

Rendered floor plan technology is a great way to provide clients a clear understanding of the project’s expectations, says Nichols. “This gives us a 3D approach that leads us to that ‘turn on the light’ moment, where the stakeholders truly understand the design before construction is underway. Rendered floor plan technology eliminates the possibility of walking into a completed space and saying, ‘This is not what I expected.’”

Other technologies gaining in popularity are 360-degree photography, which captures building data for future reference; drones, which can be used to capture construction progress photos and perform 3D scans of existing structures; and radio frequency identification (RFID) to track workers and equipment.

And just as it is disrupting all of health care, Belkofer says artificial intelligence (AI) is among the exciting new technologies that will transform health care design and construction in this decade.

“We are starting to figure out the many ways AI can aid design and construction,” Belkofer says. “How do we automate some of these human tasks related to modular and prefab construction? How does the evolution of robotics drive the ability of 3D printing? They are now testing ways to lay brick and concrete blocks with robots. These technologies are the future of design and construction.”

Funding construction projects 

In terms of funding, hospital construction budgets were in line with the previous year. In 2019, funding for new construction dipped slightly from 25% to 19%, increased from 18% to 20% for infrastructure and stayed level for facility renovation at about 28%. 

While more than half of the respondents said projects came in under budget and on and/or ahead of schedule, more than 18% said projects were over budget and behind schedule — a number that has increased gradually over the years. 

Pollitt says this steady rise may be related to the increasing complexity of hospitals and the need for contractors to get involved earlier. “Hospitals that don’t hire the right team early in the process will soon be dealing with schedule overruns and budget overruns. Even 10 years ago, hospital systems were not this complex.”

And the vast majority of hospitals are funding renovations and expansions (74%) of acute care hospitals versus new construction (31%), a trend likely to continue in 2020, according to the survey. Forty-eight percent of respondents are planning to increase spending on renovations/expansions this year. 

Pollitt says those numbers are consistent with what he is seeing in the field. 

“Hospitals are upgrading older facilities to incorporate the latest technologies and services to better please patients, which is cheaper than new construction,” he says. “The rise in physical plant infrastructure upgrades is in line with the increase in renovation.”

ASHE President Jeffrey Henne, FASHE, CHSP-FSM, CHEP, CHC, safety and emergency manager at the University of Pennsylvania Health System, Philadelphia, says the increase in funding for boilers and chillers is also linked to energy measures and incentives that provide payback to the facility. “I know for our hospital, we received more than $200,000 for chiller optimization,” Henne says.

Although the percentage of facilities increasing funding for off-site building dropped from 51% to 41% in the last year, Sprague says the move toward outpatient facilities is still a trend. Health care systems are moving more procedures from inpatient to outpatient settings to diversify revenue and prepare for new payment models. It’s also a smart way to move into a new area without building an entirely new facility.

“Consumer willingness to get care in nontraditional environments continues to push health care off-site, which drives workload, staffing and facility operation,” Sprague says. “Alternative payment models are also a factor in the shift toward outpatient care.”

The survey shows more than 26% of hospitals are building or planning to build medical office buildings over the next three years; and roughly 22% have ambulatory facilities in the pipeline. Freestanding imaging centers and emergency departments are also on the rise. 

“There is a continuing effort to take patient care into the communities,” Nichols says. “New equipment and communication technology are improving home care support. Through the design and construction of urgent care centers and hospital system-sponsored specialty clinics, the trend continues towards off-site patient access.”

The survey also showed an increase in critical access hospital projects, which continue to grow in importance, Sprague says. “Critical access provides emergency treatment to any demographic a health care system plans to serve, including rural areas. Critical access is a key concern when planning a network of facilities,” Sprague says.

And although the survey found that construction for acute care hospitals dropped slightly from the previous year, that doesn’t signify a major shift in that area. “Hospitals are putting a huge amount into renovation and construction of existing acute care,” says Pollitt, citing survey results showing 74% of acute projects will involve expansion and/or renovation.

Investing in the future

Continuing ongoing trends, the survey showed hospitals are investing in behavioral health care and emergency and ambulatory care. While funding for behavioral health dipped from last year, it is still very much a focus for hospitals and health systems dealing with increasing numbers of behavioral health issues. 

“We’re doing a lot of behavioral health work, and that will be a trend for the near future,” Sprague says. “As a planner, we are working to integrate behavioral health with the rest of the system to make sure it’s compatible. Blending these systems together in one design maximizes efficiency and minimizes duplicity.”

Major expansion and renovation is often needed in older hospital buildings that aren’t equipped to handle the needs of today’s behavioral health patients, Pollitt says. “Today, we have drug issues, more violence and lockdown units. The anti-ligature requirement alone often requires major construction,” he says. 

The survey showed hospitals are also investing in pharmacy, imaging, and emergency and ambulatory care construction projects. 

Twenty-six percent of hospitals have pharmacy projects, with roughly 36% planning new or replacement projects in the next three years, and more than 65% planning renovations or expansions. Nichols says the pharmacy construction is likely linked to U.S. Pharmacopeia regulations, which usually require infrastructure and operational changes in the facility. 

“Meeting these regulations has generated a big push right now for pharmacy renovation and expansion,” says Nichols, whose firm is now handling 18 pharmacy projects in the Chicago and central Illinois area.

Other building projects on the rise include cancer centers and children’s, heart and rehabilitation hospitals. In terms of what to watch, Pollitt says orthopedics are quickly shifting to an outpatient model, driven by advancing technology that negates the need for an overnight stay. “A lot of orthopedic work is moving toward an ambulatory environment,” Pollitt says. “You can get a new hip at 7 a.m. and be home later that day.”

Certification and commissioning

A growing number of facilities are commissioning — conducting an audit to review energy performance, safety and sustainability, among other factors. This year, 74% of respondents reported commissioning, up from 72% last year. ASHE, which offers Health Facility Commissioning Guidelines as part of its Sustainability Roadmap, would like to see these numbers increase, says ASHE Deputy Executive Director, Advocacy, Chad Beebe, AIA, CHFM, FASHE. 

New this year, the survey questioned hospitals about qualifications required of general contractors. 

The majority (62%) require contractors to complete Infection Control Risk Assessments. In addition, 26% require contractors to have Certified Healthcare Constructor (CHC) credentials, while 6% require ASHE’s newest certification program, Certified Health Care Physical Environment Worker. 

“Hospitals are different. We operate around the clock, and we work hard to protect our patients from construction issues that may be common in other types of buildings, such as dust or noise,” Beebe says. “By requiring workers to earn this new certification, hospitals can reduce risks by ensuring people working in their facilities understand important patient safety concepts.”

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Beth Burmahl is a freelance writer based in Lisle, Ill., and Jamie Morgan is editor at Health Facilities Management.