So you've been charged with renovating or expanding a surgical facility that has run out of bays and beds and outlived its usefulness. There's a lot of dust and dirt in your future, but to help you keep the delays and disruptions to a minimum, we asked a few architects to tell us how to get the best results from your project.
"Don't let any architect tell you that a remodel's going to be easy," says John A. Marasco, AIA, NCARB, of Marasco & Associates in Denver. "You'll have noise, dust, vibration, plastic sheeting hanging all over the place, temporary walls, rerouting." You might be able to avoid a temporary shutdown by hiring contractors to work only nights and weekends, but this may cost too much and take too long.
The value of experience
First and foremost, hire experienced design and construction staff early in the process to advise you on the possibilities of your renovation or expansion. Experience building surgery centers as opposed to a general healthcare background is essential, says Mr. Marasco. "You don't want somebody learning on your project."
So is their ability to handle occupied projects. "In general, I'd recommend that a facility owner be very particular about who they hire for a renovation to a functioning facility," says William Massingill, AIA, NCARB, chief executive officer of Polkinghorn Group Architects in Austin, Texas. "There's a relatively small number of contractors throughout the country who are really good at working around business operations and can minimize the daytime disruptions during a project."
Be sure that your early discussions with design and construction professionals include a definition of the project costs, and particularly the scope of work and contingency payments.
"Know what you're paying for, and what you're getting for that price," says Paul Stegenga, AIA, of Stegenga + Partners in Alpharetta, Ga. "And beware of the lowball." An unusually low projected cost may reap lackluster results, he says, then cost more to upgrade. "Super cheap is not what your surgeons are going to expect, and certainly not what your staff and patients are going to expect."
Mr. Stegenga also reminds administrators that few renovation projects proceed without surprises. "Any renovation project is full of unknowns," he says. "You never know what you'll find when you take out walls and ceilings." Maybe forgotten pipes or electrical lines are discovered in a wall, or your IT consultants have run data cabling since the last major project. These discoveries will likely force a change of plans or extra work. "How will your architects, engineers and contractors be compensated for these additional surprises?" asks Mr. Stegenga. "Hourly, or as a percent of the cost of the work?" Not knowing could lead to an even nastier surprise when the bill arrives at your desk.
In both situations, he says, "the best protection is having [those factors] clearly identified in your contract, up front." And, in preparation for the unexpected fixes, be sure to count in a contingency budget. Mr. Stegenga recommends 10 percent of the total budget for that purpose if your building is relatively new, the architect is familiar with the structure and documentation has been kept up to date. If, on the other hand, it's an older building that's been through a few makeshift fixes over the years that might not have been fully documented, the contingency budget should be closer to 25 percent.
Up to code
Above all, says Mr. Marasco, your architect should be familiar with the codes governing construction and should be able to work with the multiple layers of state and local agencies that enforce them before the project leaves the drawing board.
"The biggest issue from an administrative perspective in adding to or remodeling an existing surgery center is getting somebody who is familiar with the process of what you have to go through to get approval," he says.
This qualification is important because, in all probability, the codes have been significantly updated since your facility was built. "These things have changed almost yearly over the past 20 years," says Mr. Marasco. The code changes will most likely raise the issue before authorities as to whether the entire facility will need to be brought up to the standards under which the renovated portions are being built.
"If your OR is 15 or 20 years old and you're adding on, you may be opening a can of worms," he says. "It could be easy to do, but it could be a nightmare." Whether an entire facility or just the improvement will be required to meet current codes is a decision made in each specific jurisdiction, but the result may limit the amount of renovation or addition you can do. And retrofitting an entire facility for compliance will cost you.
"An old surgery center can really take a lot of work and money to renovate," says Robert H. Blau, AIA, vice president of Mason Blau & Associates in Clearwater, Fla. He says a review of the potential costs of renovation (including compliance efforts, temporary closings and other expected operating expenses) must be compared with the costs of other options, including new construction or the purchase and outfitting of another existing structure, to determine a project's financial viability. In some cases, a renovation just isn't as cost effective as building an entirely new center, he says.
The renovation ripple effect
The architects remind potential renovators that every change has a consequence, and that the downstream effects of expansion can easily snowball. The addition of an OR will require additional space in pre-op and recovery to handle the expected increase in case volume, for instance. Expanded or added locker rooms, break rooms and business workspaces, and perhaps a larger waiting room may also be warranted.
Don't neglect an examination of what renovation will mean to the rest of your facility, says Mr. Massingill. One commonly overlooked area is the storage room. "Storage gets minimized," he says. Since it's not required by code and it's not directly making a profit, storage space becomes an afterthought, or used for another purpose to a facility's disadvantage.
"The equipment needed at a facility grows as surgical technology grows," he says, so it's counterintuitive to reduce storage space. "I make sure the client knows that if they lose that storage space, they're going to have to put their stuff elsewhere. That's when you see corridors packed with gurneys, blanket warmers and other equipment." Since haphazard storage can inhibit your efficiency and, as a result, your revenue, "there's more value than you may think in having sufficient storage."
A renovation project is going to have to accommodate the facility's utility systems, such as HVAC, anesthetic gases and emergency power, and anything that construction codes might now require, such as sprinklers or other protection systems. The spaces adjacent to clinical rooms, above the ceiling and around the building, are critical with regards to their installation, says Mr. Massingill, since a lack of space for ductwork or other infrastructure will hamper renovation plans.
Determine where a renovation will begin, says Mr. Stegenga, and where it ends. "New construction, new material, new finishes or paint next to the old makes it look even older," he says, noting that patients will likely notice where the new flooring stops, for instance. "Identify with your architect where the new and old are going to meet, and what you can do with that," he says. "It might not be optimum, but what's acceptable?"
Working during the work
Stay on top of the authorities' necessary guidelines for a surgical facility undergoing construction, says Mr. Blau. For instance, most state departments of health mandate the submission of and compliance with an infection control risk assessment plan. A standard form is available, which you can customize. Mr. Blau recalls how, on a recent project, vigilance to the policy actually led to quality improvement. "As we went through, the facility's infection rate went down below what it was, probably as a result of the extra cleaning being done due to the work. It hasn't gone back up since then."
Keep your staff informed and up to date on the construction process as well, especially if it's a multi-phased project that changes the operational layout of the facility as it proceeds. "Every employee of your facility should be made aware of the timeline and any potential problems," says Mr. Marasco, who recommends weekly on-site meetings to keep them in the loop. "You don't want to just shock them down the road, like when they go to storage to look for something and it's not there."
In the overall analysis, architects advise you to keep the future in mind when planning a renovation, for their benefit and for yours. "Always make sure the renovation aligns with your short- and long-term goals," says Mr. Stegenga. After all, he says, an overly restrictive budget may someday limit your facility's possibilities, while a surging case volume may someday recede from an overbuilt expansion.
If you've got plans in mind for the future of your center's business and physical expansion, Mr. Massingill says, it's best to give your architect a view of those projections. They're not the ones running the business, of course, but your vision can help them plan for any future projects the center might undertake. "Very seldom do facilities design for expansion," he says. "But if you've done your homework up front, it can be easier to add a future expansion."