Inpatient demand from an aging population and a desire to provide the right service line mix in customer-centric spaces are driving many health systems to expand and future-proof their hospitals. With space-constrained campuses and the increasing cost of land, growing vertically is often the only option.
Sometimes this means future demand is met by proactively including one or more stories of unfinished “shell space” in a new hospital or tower. These shelled floors conveniently remain available for just-in-time design and construction of the interior, allowing a hospital to meet future demand later, with less time and investment than building a new facility.
Alternatively, health systems might consider a vertical expansion, which adds one or more levels to an existing building, to meet their growth objectives. These are particularly complex construction projects. But with insight into unique project nuances, along with some best practices, health systems contemplating a vertical expansion can set the stage for success.
Awareness and Understanding
It is helpful to understand the distinctive elements of these projects and how they can impact the entire facility and campus before embarking on one. “Unlike greenfield construction projects where the first several months are typically spent preparing the site for construction, vertical expansion schedules are on the critical path almost immediately,” said JE Dunn Senior Healthcare Project Manager Nick Paradossi. This means the building being expanded—as well as the rest of the campus—are significantly impacted as soon as, and even before, construction begins.
Since the structure must extend vertically from the top story of the building and the roof is eventually removed and replaced with a floor for the first level of the new expansion, the hospital’s top story is impacted the most. To do this with as little disruption to ongoing hospital operations and revenue as possible, work on the top story is methodically done through numerous small portions at a time. Sam O’Connor, healthcare preconstruction services director at JE Dunn advises clients to account for this when contemplating the financial ramifications of a vertical expansion. “Consider the impact of phasing and multiple short-term relocations of spaces and services from the building’s top floor, and consequently, the potential impact on hospital revenue and overall financials. It’s easy to forget this piece of the planning and depending on the services located on the top level, this can have significant implications for project phasing.”
Understanding vertical expansions’ impacts beyond a building’s top floor is also important. “We aren’t just adding one or more stories,” explained Paradossi. “We’re also preparing the entire building to support the expansion. This involves connecting to, extending or upsizing things like structural supports, elevators, HVAC, plumbing, electrical, pneumatic tubing, and technology to provide the strength and utilities necessary for the expanded floors.” Therefore, work in many areas of the facility and planned utilities shutdowns are likely throughout the project.
Anticipating the project’s influence on the rest of the campus is also critical. “Cranes, frequent deliveries of materials and equipment, temporary hoists or stairwells on the exterior, and extensive safety barriers are expected with vertical expansions,” said Forrest Wilson, vice president at JE Dunn. “This can impact parking, traffic flows, entrances and exits, helipads and even the exterior aesthetics of the building and campus while construction is underway.” Once hospital leaders and staff fully understand the ripple effect beyond the top of the building, the more adequately prepared they will be.
Early Detailed Planning
Given the unique nature of vertical expansions, their degree of complexity, and the significant level of construction involved as soon as they begin, detailed planning should commence well before construction to minimize disruptions and ensure success. In fact, some facilities are designed and built with a future expansion in mind. “Since vertical expansions impact so many facets of a building, including stairwells, air handling, foundations and the structure” cautions David Harlow, healthcare preconstruction services director with JE Dunn, “it is never too soon to make decisions and start accounting for this in early in design.”
But even if an existing building was designed with a future expansion in mind, successful vertical expansions require months of investigation, research, verification, documentation, and coordination with the facility to inform construction plans. Many details of the existing facility must be identified and confirmed during preconstruction to optimize efficiency and eliminate surprises during construction.
“During our early investigation process on a project, we discovered the entire hospital water system lacked valves to isolate sections of plumbing,” said Paradossi. “Thanks to that early discovery, we were able to preemptively add valves to help minimize impacts to critical areas during our expansion, while also improving the facility for future maintenance activities.” Providing construction partners with early access to many areas of the building for investigation and making hospital staff available for important preconstruction conversations and decision-making helps further ensure adequate preparation and ultimately, project success.
Another facet of early planning crucial to project outcomes is thorough logistics and safety planning, including considerations for patient comfort and satisfaction. “Because construction occurs on top of the existing facility, we coordinate closely with our clients to plan quiet hours, implement temporary white noise systems, and utilize temporary barriers and insulation to minimize noise and vibration for sensitive patient populations,” explained Wilson. “We want to ensure patients remain both safe and as comfortable as possible during a project,” he said.
Experienced construction teams should also develop plans with hospital leadership to minimize disruptions to patient and staff flow throughout the facility and campus—and it is equally important to proactively ensure suitable temporary locations for entrances, exits, parking spaces, elevators, ambulance drop-offs, helipads, loading docks, and countless other aspects of the facility that could be impacted during various phases of construction.
According to Sara Curry, JE Dunn’s prefabrication integration director, construction partners can also leverage innovative tools and best practices to help accelerate construction schedules and minimize disruptions to a hospital’s campus. “We can use technology to enhance safety and logistics planning, for example, while also taking advantage of offsite prefabrication to minimize the impact of construction activity on the facility’s staff and patients. Best practices such as these further ensure schedule certainty and minimize overall project risk.”
Robust Communications Planning & Expectation-Setting
Given the far-reaching impacts of vertical expansions, investing time and resources in thorough communication planning is wise. “I can’t stress enough how important extensive communication planning is for these projects,” said Paradossi. “Construction and hospital leaders should partner early in preconstruction to determine the right points of contact and different audiences for various information throughout the project, and document and agree upon a detailed communications plan.” He pointed out that staff who are not directly impacted by the project should also receive kickoff communications and frequent updates to eliminate confusion and avoid potential frustration with things like temporary changes and construction activities on campus. “The more people know what to expect and the reasons behind plans and changes, the better,” he stated.
Change management efforts and communications planning should also take patients, visitors, and the community into consideration. “The public relations aspect of these projects should not be overlooked,” said Wilson. “Patients, visitors, and other key community partners also need to understand how the project could impact different aspects of the facility and campus. That includes information about the project, as well as updated and even additional signage and wayfinding to minimize confusion when people are onsite.”
As Curry noted, contractors can assist with these communications efforts by leveraging their suite of virtual design and construction tools. “We can use technology to support and complement a health system’s communications. Having visual aids to accompany those messages can help people better understand the plans, temporary changes, and phased timing, as well as generate overall support and enthusiasm for the project,” she said.
Setting The Stage for Success
While every project is unique, greater understanding of everything involved with vertical expansions can help hospital leaders be better prepared and lead their organizations through the process. Armed with experienced partners, knowledge and clear expectations, extensive preparation, and fine-tuned communication planning, hospitals can confidently forge ahead with their growth objectives and expansion plans.
Kyle Drake is Healthcare Vice President.