09:00   Adaptable Futures III: Hospitals
Chair: Stephen Kendall
09:00
20 mins 		DYNAMIC FACILITIES MANAGEMENT TO ADDRESS CHANGE
Joan Saba, David Hanitchak
Abstract: Healthcare facilities must respond to changes to accommodate new technologies and practice patterns, and to react to new incentives and financial drivers. Change occurs over the life of the building, but the speed and frequency of these change drivers have increased, creating a tipping point in facilities management. While the gestation of a building might take five years to plan and deliver, the gestation of technologies, practice patterns and financial incentives can be as little as two years. The existing facilities design and construction procurement process and methodology in most developed countries, whether privately financed or PFI contracting, often focuses on commissioning services for first use, foregoing future adaptability. Change represents risk to the delivery of a project, which are often mitigated and managed by designing and delivering a project as quickly as possible. This paper explores a new paradigm for “Open-Ended Design” that, regardless of different approaches to facility challenges in developed countries, presents a model for “change ready” procurement focused on adaptability. The paper includes practices from one leading U.S. academic medical center, Massachusetts General Hospital. Massachusetts General Hospital’s (MGH) recent approach to a major 500,000 SF (46,450 SM) building with 150 inpatient beds reflects challenges typical to most Academic Medical Centers (AMCs). MGH is a complex organization with three-part missions of education, research and healthcare. It is located on an urban site, landlocked, and occupies multiple buildings of various vintages and design. This institution’s journey to develop a process to integrate multiple goals—functional, strategic, organizational, operational, business, design, lifecycle, sustainability—presents a test case for this new project delivery approach that accommodates change to support multiple missions over time. The paper reviews project delivery tactics and strategy that balance the short term needs for functionality and ROI with longer term flexibility and adaptability. It explores processes to include representation for all of the various project goals, though in a rigorous and staged manner, and to balance the various institutional, service and support goals to deliver a project as quickly as possible while managing risk.
09:20
20 mins 		BEYOND ESTATES STRATEGY? BEYOND MASTER PLANNING? OPEN PLANNING FOR FUTURE HEALTHCARE ENVIRONMENTS
Phil Astley
Abstract: Abstract This paper explores open planning of the future healthcare estate beyond the traditional hospital site. It proposes the need for an open planning approach which can be applied to the changing healthcare environment across settings. Existing strategic planning approaches and investment choices will need a clear understanding of their future logistics, technological change and environmental stewardship. At the same time the vertical integration of networks of care are opening up the possibility of organisations taking on a sub-acute community provider role of service and estate. Current processes are based on single site, long term, top –down, phased development ‘master plans’, however a new range of development scenarios are emerging across Europe. They illustrate, in part, the theoretical development of compact ‘open’ building systems and ‘core’ hospital concepts. This paper proposes scenario planning concepts as a strategic development technique to facilitate the potential of an open approach that is better aligned to a healthcare organisations future business plan.
09:40
20 mins 		DYNAMIC FACILITIES DEVELOPMENT: A CLIENT PERSPECTIVE ON MANAGING CHANGE
David Hanitchak, Malaina Bowker
Abstract: Healthcare is complex and dynamic, and hospital facilities reflect that complexity in their response to multiple influences and demands to accommodate change. Large hospital facilities, and particularly academic medical centers, support a range of uses, and mix low intensity functions (administration, logistics support, ambulatory care) with mid intensity use (ambulatory exam, diagnostic and treatment) and high intensity use (highly serviced acute inpatient units, diagnostic and procedures, clinical and research labs, high-tech); despite the demands for frequent change there is a need for high reliability and intolerance for disruption. Massachusetts General Hospital (MGH) is one of the premier academic medical centers in the United States, and its main campus is an aggregation of 25 buildings built primarily over the last 100 years. This paper compares basic building elements (floor plate size, floor-to-floor heights, structural grid size, and others basic dimensions) of our existing buildings by clinical function (inpatient, outpatient and procedural) throughout their lives: what expectations were placed on the initial design of the buildings by their use, and how clinical practice patterns have changed expectations over time for newer buildings. We trace impact of change influences on functional demands by metrics such as square footage by room type, and number of functional rooms (beds, exam rooms, operating rooms) per floor square footage to track the change in necessary support space to by use type, and to indicate the relative efficiency of our buildings. Older facilities at MGH have been remarkably adaptable and have accommodated new clinical practice patterns, new equipment and new code requirements, and have had long lives for their initial use; several buildings have significantly extended their useful lives by accommodating other, lower intensity uses. Despite the absence of today’s larger grid sizes, increased floor to floor heights, and super-sized infrastructure, through an aggressive program of capital reinvestment we have been able to maintain use of a 70-year-old bed tower and an almost 80-year-old outpatient clinic prior to opening new replacement facilities. This apparent adaptability of existing structures to accommodate new air flow regulations, state-of-the-art equipment, and endless changes in practice patterns has been forced in large part by the need to maintain ongoing hospital operations in a fully occupied facility. Adaptability of our older structures comes at a premium cost however: the financial investment required to adapt these buildings to respond to change influences is higher with the older buildings than with newer buildings. Yet some of our oldest buildings have serviced the hospital for over 50 years before receiving a major floor and infrastructure overhaul. The average cycle of major investment varies by use for our existing buildings; the lowest intensity of use has the longest cycle of major investment, and the most intense uses have the shortest cycles, but are augmented by planned annual upgrades. We invest in developing new facilities for on-campus clinical and administrative space to grow (increase volume), to increase capability (by increasing operational efficiency, support new practice patterns such as including space for families in exam and patient rooms), to renew existing facilities and replace obsolete facilities. It is easier to build in additional capacity in new buildings than to retrofit old; however the cost of new buildings has increased significantly and assembling sufficient capital funding for a large project is difficult and time consuming. Delivering a major building takes at least 5 years. Given the financial condition of hospitals in the United States, there is a focus on operational and financial models, particularly Return on Investment (ROI). Investment in infrastructure is challenging in the face of the demand for quick return since the fit-out, rather than the performance of the infrastructure, yields ROI. Renovations, on the other hand, respond quickly to department level demands, and can be 'good enough'. We would likely reduce cost, schedule, disruption and increase building performance of we built with greater capacity for change and if we made a greater investment in infrastructure, our buildings would likely last longer and perform better over time. Quantifying the costs of additional capacity and infrastructure would help make the argument that the investment will pay off. KEY WORDS: change ready hospitals, academic medical centers, hospital facilities, return on investment, adaptability