Building Operating Management

Planning Is Easier Said Than Done

On health care campuses, constant change magnifies project challenges

By Randy Keiser   Design & Construction

Big Jobs: Campus Renovations

A renovation program on a campus sets off a reaction that can be overwhelming. More buildings mean more existing conditions to deal with and more surprises as construction proceeds. Also, as the number of people affected multiplies, so does the difficulty of getting decisions approved. Scheduling can become a nightmare. Differences among project team members are magnified. A project in one building gets in the way of operations at other buildings. To top it off, everything happens in a spotlight more intense than anything a single-building renovation could ever attract.

This section looks at strategies that have met renovation challenges on different kinds of campuses. Not surprisingly, many of the underlying principles are the same — the need for careful planning, for example, and the importance of effective communication. Also no surprise: Those things are easier said than done. To help get them done, this section highlights key steps that make renovation programs succeed on different campus settings.

Health care institutions face myriad challenges to deliver quality care to an increasingly sophisticated patient population. As a result, many institutions are involved virtually nonstop in renovation projects designed to enhance the range and quality of the services they provide.

The challenges facing building owners and facility executives planning a renovation are magnified on a health care campus, which must address such issues as infection control, utility loads, switchovers, service to physicians and patients, and the impact of design on existing facilities and activities, such as emergency helicopter approaches. The issues are further exacerbated by the economic trends in today’s health care field. Frequent turnover in administration, as well as architects, creates “short-term institutional memory” on campuses that have seen many major additions and alterations through the years.

Minimizing disruption to ongoing hospital activities and ensuring a successful, cost-effective project requires careful planning by an experienced health care design and construction management team, including a construction manager who knows the history and needs of the institution.

Selecting materials that are appropriate, cost-effective and available to meet the construction schedule is one of the key decisions during the planning stage. Pricing, delivery and scheduling information is essential to making the right decision for the location.

Consider additions at two hospitals, one in Evansville, Ind. and another in Nashville. In both cases, the question of whether concrete or steel would be the least expensive structural material arose. An analysis showed that the project in Evansville would be less expensive to construct of steel, while the project in Nashville would be cheaper to build in concrete because of local differences in material costs, labor and staging issues.

Another challenge is selecting and ordering materials with long lead times. On many health care campuses, brick is the traditional building skin; renovations, additions and new buildings must harmonize with existing facilities. On one project, there was a one-year lead time for delivery of brick to match existing structures. That fact necessitated early decisions so orders could be placed during the planning and design process.

Given the fast-track nature of health care construction, these and many other decisions must be made before the design is completed. Design issues might also arise from an expansion’s potential physical impact on existing buildings. For example, an addition may create a wind tunnel or block views from existing buildings. Its height and siting may affect the helicopter flight path and landing approach both during construction, when cranes will be in operation, and permanently thereafter. For any facility with a helicopter landing pad, a copy of the Federal Aviation Administration handbook should be a standard tool for all planning sessions.

Site Constraints

Key project elements that create challenges on a health care campus are related to constructibility, and these are multiplied on a multibuilding campus. The design and construction team invariably deals with site constraints imposed by multiple buildings, often linked by skybridges; that’s especially true on more congested campuses. The constraints affect not only the design of a renovation, addition or new facility, but also the construction staging, especially the placement and operation of cranes.

Work sequencing plays a critical role in solving many of these dilemmas. It might even make sense to redesign an addition or renovation to reduce disruptions to ongoing activities. In one case, a small addition was built on one end of an existing building to accommodate those using the structure while the other end of the building was being remodeled. This resulted in a significant savings over the cost of renting temporary space while providing additional permanent “swing” space to meet future needs.

Minimizing inconvenience to patients during construction is one of the key goals of every owner. The owner, construction manager, architect and program manager must work together to develop a design that can be constructed quickly and efficiently. In one case, a projected five-year construction schedule was halved to avoid inconvenience to patients and potential loss of revenue.

Any construction project requires a plan to provide additional temporary and permanent parking facilities. In some cases, it makes sense to construct new permanent parking facilities before beginning construction on the renovation or addition itself. For example, on one project an existing parking lot will become the site for the construction crane once a new patient parking garage is finished.

Owners typically resist this approach at first because parking has little or no revenue attached to it. But they reconsider when they factor in the potential loss of patients. Sometimes, the solution requires a bit of ingenuity. On another project, valet parking was provided for patients during construction. In addition to making provisions for patients and visitors, separate temporary parking must be provided for contractors.

Access and wayfinding are also crucial planning issues. On large, multibuilding health care campuses, it is not uncommon to hire an independent consultant to help ensure that patients, staff and visitors can find their destinations during construction.

Infection Control

Recognizing the potential impact of the release and movement of bacteria during construction — as well as the ongoing issue of infections — infection control risk assessment and management are an integral part of the planning process. Effective construction sequencing and placement of air handling units are key to effective infection control, both during construction and over the long term.

This challenge is complicated by the presence of multiple buildings. Their proximity to one another creates the potential to draw contaminated air from the construction site into a neighboring uncontaminated building. What may not be so obvious are the effects of their configuration on air currents, an issue that must be analyzed before work begins.

Central receiving, storage and trash removal, both temporary and permanent, are other issues that become more complex in a campus setting. The design and construction team must consider such issues as whether an addition requires a new loading dock or can share an existing central loading dock; the route that must be traveled to remove trash and medical waste; and the potential impact on future expansion.


A renovation or addition on a multibuilding campus sets off a chain of important utility planning questions. Many health care facilities could not have foreseen the amount of expansion that has taken place over the course of a decade or more and the effect on utility capacity. The central plant may be boxed in by additions, with little or no room to expand the plant to accommodate a new chiller or emergency generator, much less a 10,000-gallon diesel fuel tank. When the additional load exceeds existing capacity, an analysis must address the economic feasibility and constructibility of vertically expanding the central plant versus locating an independent utility plant within the new building itself.

Looking Closely

Even a small addition can have a significant impact. On a recent project, analysis showed that tying a small addition to the existing chilled water system would raise the water temperature 1 degree, which would have affected the functioning of MRI equipment across campus. The analysis of loads and capacities extends from the major power and HVAC utilities to medical gases and pneumatic systems.

At the planning stage, the design and construction team must not only address load and capacity but also the strategy to be followed when the utility shutdown and cut-over occur during construction. Here again, the situation will be complicated by the size and complexity of the campus.

Lives depend on effective scheduling, communication and coordination. A tie-in to oxygen lines requires a shutdown of all connections downstream. If the downstream facility is an outpatient surgery suite, the shutdown can be scheduled at night. However, if it is a 300-bed in-patient facility, portable oxygen bottles will have to be supplied. Setting that up is no easy task; indeed, the shutdown may not be feasible at all from January through March, peak seasons for both flu and elective surgery. These situations require close communication and coordination between the construction manager and hospital administration.

Communications, coordination, planning: those qualities are important throughout the renovation of a health care campus if the institution is to maintain its image as a safe, sterile, highly efficient and healing environment for patients while contending with temporary facilities, excavations, construction equipment and an army of contractors.

Randy Keiser is health care group manager in the Nashville office of Turner Construction Co., a subsidiary of The Turner Corp., the leading general builder in the United States. He has extensive experience with construction of health care facilities nationwide.

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  posted on 9/1/2002   Article Use Policy

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