As the Puget Sound region continues to grow and evolve, more health care facilities will be necessary to meet growing demand. The Puget Sound Business Journal recently held a Thought Leader Forum with industry leaders about important issues to consider when making decisions regarding health care facility design and construction.
The Puget Sound Business Journal Thought Leader Forum participants were Keith Honsberger, Senior Vice President, Kidder Mathews; Mark Howell, Senior Vice President, Skanska; and Brian Phair, Chief Executive Officer, PCS Structural Solutions.
What is the biggest market trend you are following now?
Honsberger: Greater access to care through the Affordable Care Act has increased expansion of health care providers throughout Western Washington. Much of this growth is focused off the hospital campus, where the goal is to provide better access for patients and drive referrals back to the hospital system. Hospital owned urgent care facilities are locating in suburban markets where patients live and shop. In many cases these new urgent care facilities are competing with independent private practices.
Howell: Changes in political leadership and the probable repeal of the Affordable Care Act have led to uncertainty in the health care market, both nationally and locally. Health care organizations are increasingly concerned about how reimbursement structures will affect their design and building programs. Most health care providers are just hitting their stride in implementing plans that align with the Affordable Care Act (ACA) to serve their communities, and the potential shift in direction is jarring. Our customers want to know what the future holds so they can focus on what they do best: caring for patients.
What are some of the certainties in the market?
Howell: Facility flexibility amid rapidly changing technology is a priority. We're lucky to have some of the best health care providers in the country right here in our region, and they are constantly striving to offer leading-edge treatment options to the community. This means, essentially, that they want to work with designers and contractors to build today what can still be used tomorrow - and to do it in a way that limits the future costs of converting spaces for new equipment, technologies or uses.
Honsberger: A clear trend of hospital employed physicians continues to increase. Hospitals remain on course to add physicians through strategic acquisition of private practices or the recruitment of individual physicians. In many markets hospital acquisitions of private practices has resulted in an increase to the existing supply of medical office space. Along with rising vacancy rates, time required to release vacant medical office space has increased.
How are facilities achieving the goal of remaining flexible in order to incorporate future technological advances?
Howell: Collaboration in the early stages of design is critical to understanding a customer's needs, both for designers and contractors. Early involvement allows designers to create spaces that support both immediate needs and long-term goals, and for contractors to weigh in on constructability related to future flexibility. Early collaboration can take many forms, but one of the chief approaches is to move away from the traditional design-bid-build model of construction and toward GC/CM, design-build and integrated project delivery. Aligning the full team with the customer's goals-including an understanding of their long-term vision - yields the best results for everyone. On a deeper level, we consider how the facility functions. How mechanical, electrical and plumbing systems integrate may impact adaptability. The design of nurses' stations could significantly impact patient care. We want to work with our customers from the start to understand their needs and to create solutions that allow them to provide the best, most efficient care possible.
As our region grows, are there additional challenges?
Howell: Absolutely. First, there's increased patient volume. About five years ago, there was a wave of large expansions to our region's primary medical centers. Already, we're hearing from customers that they're looking at what's next. Land in the urban core is at a premium, traffic is not getting better and health care providers are wrestling with how to address that. We've already seen many prominent providers placing outpatient clinics in more suburban areas. Smaller inpatient facilities in these same areas may be the next trend to watch for. As a contractor, we must be nimble in helping our customers bring facilities online quickly, even during the region-wide construction boom. Assuring the proper resources are available is another reason to engage teams earlier in the process.
Name a few structural engineering challenges when designing health care facilities versus typical buildings.
Howell: A few challenges stand out that affect design and construction approaches. They are:
Operationally active hospital environments can affect everything. Patients are most important, so we have to be able to phase and perform work with active environments in mind.
Tight restrictions on design requirements around Mechanical, Electrical and Plumbing systems (MEP). For example, air exchange requirements, humidity controls and equipment loads for electrical.
The need for a structural system that limits vibration and yet allows for future flexibility requires a unique approach.
Phair: An owner's representative on a health care project usually represents the decisions of dozens if not hundreds of executives, and they have a large enough challenge on their hands already. Structural consultants in health care need to be much more proactive and not simply reactive to the architectural design. This mandates that structural engineers are well versed in other areas, such as medical equipment floor vibration criteria and complex MEP systems, while constantly maintaining the goal of facilitating great architecture and efficient construction.
How have technology advancements changed the structural design process for hospitals in recent years?
Howell: Models of care have completely changed within the past 10 years, to include robotics, handheld smartphone devices, and wireless technologies. This has inherently changed the physical environment where health care is delivered. Structurally, this can affect the member sizing and shielding requirements. It can also drive the selection of the structural system (concrete, steel or hybrid).
Phair: Yes, technology in the structural engineering design and construction process has recently changed greatly. The use of 3-Dimensional Building Information Modeling has allowed for increased coordination of building systems prior to construction - reducing risk during the construction phase of the project. Prefabricating components and even portions of buildings have also become commonplace, resulting in shortened construction timelines. Blending construction and design requires modified structural detailing from the 'traditional' approaches of the past and fuels creativity. One of the most important technical advances has been the advancement of performance-based seismic design techniques and higher-level analysis software. This high-end analysis allows us to maximize the efficiency of the design, which in turn allows for the construction of a more resilient structure, which is necessary to enable a hospital to remain operational following a natural hazard design-level event.
Any advice to someone who is considering entering the health care design or construction market for the first time?
Howell: Health care space is a very complex and detailed building type that requires very specific knowledge, training and experience. It is unique from any other building type. Try to educate yourself to the business of health care and the specific requirement of building in and around health care environments.
Phair: I would simply recommend you go into health care for the long haul, and do not chase potential projects that hit the street. Work to create a partnership culture, as hospitals tend to need structural engineering help on a monthly, and even weekly, basis. Consider forming employee focus groups with goals related to innovatively helping your health care clients. Be proactive - we have facilitated earthquake emergency response training, edited hospital structural performance specs, and created 'on call' in-house contracts for many different hospital campuses.
Do you anticipate the recent consolidation and partnering of hospitals to continue? How has this consolidation affected you?
Howell: Yes, I think the consolidation and partnering of hospitals will continue to better align with the changing health care market. This trend has created more projects in the outpatient market. As a Structural consultant on hundreds of buildings a year in the NW, you have partnered in numerous delivery methods on a yearly basis (Design-Build, GCCM, Negotiated, IPD, etc.).
Which one do you feel is best for health care?
Howell: It varies based on the proposed scope and complexity of the project. For larger projects with a variety of design elements and phasing, we believe more collaborative methods like GC/CM, IPD and negotiated GMP are best and have historically resulted in better outcomes. We see limited utilization of design build in acute care hospitals, yet we are seeing an increasing trend to utilize design build in outpatient facilities.
Phair: Selfishly, I love the collaborative backbone behind IPD and shared risk contracts. Seattle Children's was a great example of pushing that trend years ago in the Northwest. We tend to partner on 10-20 times the amount of projects a year than an individual owner or individual working for a General Contractor or Architectural firm, which quickly creates a deep perspective on delivery methods.
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