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August 22, 2013

A Special Section of


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Skanska USA

Pregnancy center offers one-stop care for new moms

Not all healing gardens deliver as advertised
By MARK EPSTEIN Hafs Epstein Landscape Architecture

Outpatient clinics multiply as big projects dry up

Workplace health clinics are making a comeback
McGranahan Architects

Integrated delivery pays off for Kirkland hospital

How buildings help with patient care

Children's addition built to be safe after an earthquake
Coughlin Porter Lundeen

August 22, 2013

Outpatient clinics multiply as big projects dry up

  • Medical care is moving to less expensive places that can be designed and built in less than half the time of hospitals.
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    As chair of the Washington/Oregon Architecture for Health Panel, I have seen our board struggle to find substantial acute care projects to tour as part of our quarterly meetings. These projects just do not exist.

    Several years ago large-scale projects were under way at Providence Everett, Seattle Children's, Swedish Issaquah, Good Samaritan in Puyallup and the University of Washington Medical Center, to name a few in the Puget Sound region.

    Today is very different. In November we will tour a major addition to the MultiCare campus, as it is the only big hospital project coming online this year.

    Where is health care design and construction headed?

    Smaller, simpler, cheaper

    The Puget Sound region has experienced a high degree of consolidation as the market matures in favor of the strongest affiliated players. Some of the mergers and acquisitions were driven simply by the need to implement a robust electronic health record, the cost of which is extraordinary in both capital and human resources.

    Some activity was based on the need for capital itself as aging physical plants in need of repair could not easily be funded through existing operations. The capital cost associated with these affiliations has siphoned money away from the facility-renewal process at the parent organizations.

    So has the realization of a new health care delivery model. Networked facilities, strategically located throughout an institution's service area, are being developed at an ever increasing rate.

    These are smaller, simpler, less expensive 'B' occupancy (business/outpatient) buildings. Some are being developed as tenant improvements within existing space. They are relatively easy to build and relatively quick to market.

    Photo courtesy of CollinsWoerman [enlarge]
    Group Health’s Puyallup Medical Center uses a “medical home” model designed to provide better patient care. Such clinics sometimes have space for outpatient procedures.

    Not all major hospital projects have slowed. Renovations, repurposing and strategic additions continue. Some hospital infrastructure is well past its useful life and as such it is a target for upgrade.

    The scale of these expansions and renovations is not as grand as even five years ago. The projects are carefully thought out and sized to ensure a responsible rapid return on investment. But even on a major acute care campus, even as the boomers continue to age and require more complex care, it is ambulatory facilities that are driving health care construction.

    It is generally understood that health care reimbursement will change, moving from a fee-for-service model of diagnosis and treatment to preventative medicine. Health care will move from a focus of treating the sick to keeping people well.

    How and exactly when this transformation will occur is up to speculation. What is understood by everyone is that the continued growth of health care costs at their compounding annual rates will cripple the U.S. economy. We cannot afford for every fifth dollar to be spent on health care.

    Most observers believe that pressure will be imposed on the system to perform fewer procedures, tests, prescribe fewer medications -- cost less money. More than ever evidence-based medicine will be a basis for care in the future. Preventing rather than treating chronic disease will be the norm.

    Outpatient services

    The shift toward less expensive health care venues is moving forward in the face of the perceived changes.

    Even before incentives have changed, organizations are recognizing that outpatient facilities and outpatient-based delivery is where it is at. Just as medical delivery models have pushed work to the highest level of credentialed staff (i.e., the lowest paid qualified provider) so are they now pushing services into the least expensive settings.

    The new outpatient facility generally does not support a sole provider or even a small independent group practice of physicians.

    The new facilities are driven by larger institutions that in some cases have purchased existing practices. The facilities are located convenient to residential communities convenient to patient homes, cementing market share and referral networks.

    The practices are broader team based, intended to serve the whole patient. Some employ a 'medical home' model where the expanded team of providers is responsible for a specific group of individuals, or a panel of patients. These medical centers are connected to the larger institution through robust electronic infrastructure and they often include decentralized ancillary support services, sometimes including outpatient procedure space.

    Photo courtesy of CollinsWoerma [enlarge]
    This Virginia Mason clinic in Kirkland has a modular design that is more efficient to build and simpler to use. Its exam rooms can be restocked without walking in on patients.

    Modular layouts

    Prototype design forms the basis for many of these types of facilities. The depth and intensity of the prototyping process varies by institution, but the reasons and results are very consistent.

    Organizations are looking to create uniform operations and brand identity across their systems. They want to replicate their most efficient delivery settings, the best in class.

    This need is driven by several important factors. First, institutions want to develop brand consistency, messaging for the patients who may experience more than one facility within a system. Second, as more providers spend time at multiple facilities during a given week, the consistency enhances their ability to be productive as each location is more or less the same as another. Third, the prototype process has predictable cost parameters so that planning for new additions to the network can be accomplished with more assurance. Fourth, the prototype designs must be adaptively sized to accommodate a differing number of patients at specific locations.

    Additionally, this inherent scalability includes other complementary services depending on the total number of patients served at a location. While the goal is to be patient-centered, services become cost-effective with a greater patient population.

    A characteristic of these new facilities is that they are designed with layers of modularity. By this I am not speaking necessarily of prefabrication, but instead the modularity of the layout which then enhances adaptability over time. Remember that these institutions see a new future, but they do not know what or when the future will become real.

    They do know that if they can standardize work units such as exam rooms, clusters or pods, support spaces, etc., they can quickly change services within sections of their buildings with new signage not wholesale renovations.

    Again, the modularity is unique to each institution and based on its delivery model.

    Our experience tells us that these facilities are generally 20,000 to 60,000 square feet. They are 'B' occupancy buildings, even though some include observation beds whose stay is necessarily less than 24 hours.

    The buildings are located on convenient, highly visible retail parcels. They are intentionally placed close to every day community travel patterns.

    They are generally half the cost of 'I' occupancy inpatient acute care facilities, and can be designed and occupied in less than half the time as acute care. While hospital campuses remain the source of organizational pride and specialty physician consciousness, these new outpatient facilities are carrying more and more of the daily workload.

    While the design community reminisces about the days of the prestigious major medical campus projects and their associated fees, we are happy -- for now, at least -- to be designing networked outpatient centers.

    CollinsWoerman Principal Phil Giuntoli has over 30 years of experience focused on the design of health care facilities.


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