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Logical, not lavish. That’s the modus operandi of John Balzer and his facilities planning team at Froedtert & Community Health, an academic medical center located in suburban Milwaukee that includes Froedtert Hospital and the Medical College of Wisconsin (MCW). At face value, that simple credo may bring up notions of drab, blocky facilities with any particulars of personality long since value engineered away.
But for Balzer, vice president of facility planning and development, logical, not lavish means finding new, creative ways to facilitate first-class patient care without breaking the bank or making patients wonder whether they’re being treated at a hospital or an art gallery. There has to be a good reason for every element of the design, and those reasons have to be logically justified at every turn.
Balzer and his team are practicing what they preach as they put the finishing touches on the design of a $120 million renovation and expansion project, the jewel of which is a 173,000-square-foot facility that will house the hospital’s new comprehensive cancer care program. The new facility will be completed in late 2007.
The cancer center is one step Froedtert and MCW are taking to allow them to apply for National Cancer Institute (NCI) designation as a “comprehensive cancer center.” NCI is a federal agency devoted to research on cancer care, treatment, prevention and cure. Less than 50 other institutions in the country carry the comprehensive cancer center designation, which recognizes an organization with a strong commitment not only to cancer patient care but also to laboratory and clinical research.
While NCI designation would be a prestigious achievement, it wasn’t the overriding impetus from building the addition. The actual reason was that Froedtert and MCW were on the verge of bursting at the seams.
Expansion a Must
Over the past five years, Froedtert and MCW’s outpatient hematol-ogy/oncology treatment rates have risen about 33 percent and outpatient cancer surgery has grown by about 38 percent. The hospital accommodates about 80,000 outpatient oncology visits annually, but that number is steadily increasing, even as the number of cancer diagnoses remains about the same. Better treatment technology allows many cancer patients to be treated on an outpatient basis only. With growth expected to continue, Froedtert and MCW began thinking about expansion.
One of Balzer’s first moves was to call Chris Liakakos, principal and health care designer with Chicago architecture and engineering firm OWP&P. Balzer and Liakakos had worked together on Froedtert projects in the past, going back almost 20 years. The two, along with Blaine O’Connell, senior vice president of finance, William Petasnick, CEO, and Charlie Runge, senior vice president of clinical services, among others, began working on a facilities master plan to identify the types of spaces that were nearing capacity. Early in the process, the team recognized the hospital’s clinical growth projections would necessitate additional clinical space.
The next task was to figure out how and where clinical space would be added. Based on breakdowns of the projections and other factors, the team decided that cancer care was the area in which dollars would be best invested.
“The decision was driven by sheer volumes,” says O’Connell. “Growth in volumes had been phenomenal and we realized our current facility was inadequate.”
The master planning team met for two to three hours every other week throughout 2004. Balzer says master planning required a strong commitment from everyone involved, especially from top leadership, which usually sees facility planning as a task well-removed from its realm of responsibilities. But the front-end planning was worth the effort.
“Having the CFO at the table from the beginning made it a whole lot easier when it came time to get funding,” says Balzer. “He understood the intricacies of facility planning.”
“In the past, the CEO and I would see something after it had been planned,” says O’Connell. “We’d see a number and have to accept or reject it. John made every effort up front. I wasn’t left looking like the bad guy and they weren’t left looking like they were trying to pull one over.”
Working on a parallel track with the master planning team throughout the summer of 2004 was the cancer center planning committee. This committee consisted of physicians and researchers appointed by Froedtert’s CEO and MCW’s leadership. Their charge was to develop an operational and care model for the new cancer center. Balzer sat in on this committee to answer facility-related questions.
“Ideas would float around,” says Balzer. “They’d say, ‘It’d be great if the patient could just cross the hall to receive a certain kind of care.’ We’d check the floorplate, cost it out and determine if the plan would work.”
This cast Balzer as a sort of intermediary between the master planning team and the cancer center planning committee, melding the two plans to meet both teams’ goals. After months of meetings, and thousands of hours of work, the committee arrived at a plan.
“The suggestion was a new freestanding building,” says Balzer. “The committee’s desire was strong to create an identity for the cancer program.”
The committee had also developed two other options that both included all the committee’s operational and programming requirements. When Balzer and the master planning team examined the options and estimated costs, both in terms of construction costs and projected operational costs, they determined that a better option would be an addition to the south face of the existing East Clinics Building, which housed parts of the current cancer care program. Because the radiology oncology department was already located on the south side of the third floor of the existing building, an addition to the south side of that building would mean that this department could remain in place.
“If the building had been freestanding, it would have meant relocation of linear accelerators and other equipment that would have been cost-prohibitive to move,” says Liakakos.
However, an addition at that location would mean that an existing parking structure abutting the south face of the East Clinics Building would have to be torn down. The team determined that tearing down the existing parking structure, building a new one nearby that would service other Froedtert and MCW buildings, and locating the cancer center’s parking below ground — directly underneath the new cancer center — would be the most logical option. While that plan added cost to the project, the new cancer center could still have its own entrance, while dedicated underground parking for the cancer center would help with patient wayfinding.
Balzer says the decision to tear down the garage and build a new one is an example of a strategy that never could have been approved had O’Connell not been involved from the start.
“He understood the intricacies and why this was the best option,” says Balzer. “So the decision was made on more than just hard numbers.”
A glass curtainwall on the south and east facades of the building will help give the building the personality the committee sought, but white aluminum panels — the same as those used on the existing East Clinics Building — will be used on the east face and part of the north face, where the cancer center will intersect the existing building. The new cancer center will have its own architectural identity, but in areas directly adjacent to the existing building, the facade will match so that the switch from existing to new building will be relatively seamless.
Most patient areas will be located on the south side of the addition and pushed to the perimeter so patients will have soothing views of ponds and trees — and even the downtown Milwaukee skyline from the higher levels of the seven-story facility.
“The committee had listed seven or eight key criteria that had to be accommodated,” says Balzer. “We determined that all those criteria could be accommodated with an addition. The committee was just as happy with the new option. It was a very fun process. They came to realize that the addition was the right thing to do.”
With a plan in place, Froedtert and MCW was able to go public with the intention to build the cancer center, which happened in December 2004. Because Balzer and his team had done so much planning on the front end, many decisions had already been made about the building’s siting, floorplans and exterior appearance. What remained to be designed were the details of the exterior components and the fit-out of interior spaces. While the new parking structure has already been built, official groundbreaking for the cancer center is scheduled for this month.
The Hub of the Matter
As Balzer worked with the cancer center planning committee, he was delighted to recognize that the programming needs of the building being planned went hand-in-hand with a design philosophy for which he is an advocate: evidence-based design.
Evidence-based design proponents say facilities can improve patient outcomes and staff productivity. Strategies include designing patient rooms with daylight and views of nature; locating nursing stations in proximity to patient rooms; using larger, single patient rooms; and installing HEPA filters to reduce nosocomial infections — patient infections at a hospital not related to the original affliction. Above all, evidence-based design means merging a model of care with the proper facilities to support it.
In the case of the new cancer center, the goal is to support a multidisciplinary model of care for a high volume of cancer patients. The facility’s design matches that care model with a new concept the hospital calls “hub.” All specialists and support services are present and functioning in one facility and all aspects of a patient’s care can be coordinated in that same facility. Because cancer care requires multiple specialties, and many cancer patients are treated as outpatients, bringing everything together means outpatient treatment can be completed quickly and efficiently.
In the hub model, a nurse and a coordinator work with new patients to understand their needs, make appropriate arrangements with various specialists, and communicate continuously with the patient and family throughout the course of care. Patients don’t have to worry about finding their ways to different parts of the campus to receive different kinds of care. Doctors also can collaborate easily because their teaming areas and clinical space are in relatively close proximity, no matter the specialty or discipline. Nearly everything is under one roof, and often on the same floor.
Balzer partnered with an independent expert to complete a peer review of the design of the hub model. The goal was to get further input and to compare it with other similar cancer care facilities. Comparison proved to be a bit difficult, however.
“We found out that no one in the country has done anything exactly like this,” says Balzer.
As the “city on a hill” for the hub facility model and the multidisciplinary care model, Balzer is determined to prove the effectiveness of both. Froedtert and MCW have partnered with the University of Wisconsin-Milwaukee to study and quantify anticipated improvements in terms of patient outcomes and staff productivity of the new cancer center.
Froedtert is already one of several Pebble Projects — health care organizations conducting studies on the benefits of evidence-based design under the guidance of The Center for Health Design. Currently, a study is ongoing in Froedtert’s breast cancer care center.
Nothing’s Ever Easy
Even with the final design and schematics nearly complete, and groundbreaking only a few weeks away, Balzer and his staff were still examining ways to tweak the design and ensure that money is being spent logically.
“John does a great job of budget-monitoring,” says O’Connell. “He keeps me informed and we still meet to talk about refinement. I call it cost-cutting, he calls it value engineering, but really it just means making sure dollars go to the right place.”
There are at least two significant bumps in the road that Balzer is working to fix, problems that could push the project over budget if left unresolved. One of the unforeseen issues is larger clinical growth numbers than the team had originally projected.
“Our projections for clinical growth are off the mark,” says Balzer. “The volumes are exceeding our expectations. So do we stick to the program, or do we adjust based on reality?”
Balzer decided the answer is adjustment, and the plan to do that is to build out 20,000 square feet of shell space — space that had been intended to allow for future growth. Balzer says the cost of this build-out will be about $1 million.
Another wrench in the works is what Balzer calls the Katrina Factor. With the extraordinary amount of rebuilding expected in New Orleans and the surrounding areas, the prices of concrete, sheetrock and other construction materials have increased, as much as 10 to 15 percent nearly overnight in some cases. Steel fits that category as well, and with tariff and production issues, steel prices weren’t exactly stable in the first place. Additionally, rising oil prices have meant more expensive petroleum-based materials.
Balzer says he’s hearing horror stories of health care construction bids coming back millions of dollars more than expected.
Covering added costs because of building out more space and the Katrina Factor has meant remaining flexible with the design. One way Balzer and his team have done this involved rethinking the original plan for an 80-foot lobby atrium. Though the atrium was a “beautiful, airy, uplifting space,” Balzer says he recognized it as one piece of the design that may have been a bit lavish.
“Atriums are very messy in terms of smoke and fire code issues,” says Balzer. “So when we crunched the numbers of what the atrium was going to cost, we came up with a figure of between $2 and $2.5 million.”
Balzer went to Petasnick and O’Connell, and the three decided to scale back the 80-foot design and build a 30-foot-tall lobby space instead. This would free up some cash for dealing with the Katrina Factor, building out the shell space, and other hiccups over the course of construction.
“The new lobby is still beautiful,” says Balzer. “And now, if bid packages come back and we’re okay, there is money we can take and put into other enhancements.”
Another reason for scaling back the atrium, says Balzer, is Froedtert and MCW’s commitment to maintaining health care costs. “An atrium requires lots of additional maintenance related to smoke control systems,” says Balzer. “Those only add to the overall cost of health care over time.”
That careful consideration of the effect of facilities decisions on health care costs seems to be working. According to a study by the Wisconsin Health Association, between 1996 and 2004, Froedtert’s adjusted average charge per case fell from 31 percent greater than market average to 7 percent below market average. Froedtert had the lowest rate increase — 25.2 percent, as opposed to 71.3 percent for the highest rate increase — among Milwaukee’s area hospitals from 1997 to 2004. No one would contend that facility decisions are solely responsible for keeping health care costs under wraps, but they certainly are a factor.
But even if facilities are only one of dozens of factors that affect health care costs, they still play a profoundly important role in patient comfort, satisfaction and perception of the hospital. Balzer emphasizes that while logical, not lavish decisions are standard operating procedure, every decision must also be based largely on whether it will benefit patients. Of course, with strategies like evidence-based design, the two are not mutually exclusive.
Liakakos says Froedtert’s consistent patient-first philosophy is the one thing he’s noticed that separates the hospital from the pack. “The staff really understands how important it is to work for the comfort and dignity of patients.”