Navigating the challenges of building new, retrofitting or adaptive reuse
“So, can it be done?” A healthcare client asked me this question after we surveyed a building they were considering for a new specialty care procedure center and clinic. The building was in the exact location they were looking for and it was the perfect size. There was just one hang-up: it was a car dealership and auto shop, not exactly move-in ready or code compliant as a healthcare practice. Undeterred and seeing the future potential, my client and I began a project unlike any I had undertaken in my 20-year career in healthcare architecture.
This client is not unlike hundreds of other independent healthcare providers, each navigating their way through the choppy waters of accreditation, reimbursement criteria, the competition of fellow providers and customer demands and preferences. Providing first-class care and maintaining a foothold within the community requires a constant re-evaluation of services and the facilities in which care is rendered. For many, a vital component in this quest for relevancy is the ASC or ambulatory care center (ACC). The past two decades have seen an increase in the overall percentage of surgeries performed in outpatient settings. According to the Advisory Board, in 2005, 42 percent of surgeries were performed in inpatient settings. By 2020, that number had decreased to 36 percent. The surgery market is continuing to shift to ASCs, a trend sure to continue given the Center for Medicare & Medicaid Services (CMS) recent proposal to eliminate orthopedics and other surgical types from the inpatient-only (IPO) list by 2024. Given the top-quality patient outcomes associated with ASCs, the cost savings they offer and their popularity with patients, physicians and insurers, the Advisory Board is projecting a 27.6 percent increase in ASC volumes by 2027.
For any client, the opening of an ASC requires a significant investment of resources. I have had the privilege of assisting multiple clients in this endeavor using very different approaches, each bringing unique opportunities and challenges.
New Building Construction
One client, a large independent urology group, was operating out of multiple locations but wanted to consolidate resources and streamline their operational footprint into one, unified facility. For them, the main driver was efficiency for staff and patients; to create a single, high-functioning center of excellence. By building new, the client could offer all their services in the same facility and schedule a patient for an exam, diagnostic imaging or a procedure, or some combination of the three, all in the same day, which is a definite benefit for patients who live far from the facility. Constructing their own building would allow them to forgo paying rent on tenant spaces and preclude them from having to maintain numerous sites. A new building would also bring the opportunity to create an environment tailored to exact specifications, free from the constraints of existing infrastructure. The challenges included having to re-imagine their space as a single entity, finding a site that was in their target geographical area, and working through the municipality’s building design and approval process. The result was a beautiful and highly visible facility that has allowed this client to continue providing care for the patients they already had, while also becoming a more prominent player in the community and, thereby, drawing new patients from outlying areas.
The new urology ASC with prominent signage has supported the client’s goal of increasing awareness and becoming a regional destination for all urology needs.
Existing Facility Renovation and Reactivation
Another client, an award-winning orthopedic provider, had seen their patient numbers steadily increase to the point where they needed additional space to keep up with caseload demand. This client found an opportunity nearby; a different specialty provider had recently shut down operations throughout the state, leaving a local, vacant ASC in need of a new tenant. This available space would allow our client to expand their practice within their region without the disruption of an addition to their current facility. We surveyed the facility and provided a report detailing the scope of work needed to re-activate the space. Our client would be taking occupancy as a new tenant, so they needed to consider the following, all of which potentially differed from the previous occupant:
- the codes under which the ASC was originally designed versus the current code requirements that are triggered by the renovation and re-activation of the facility;
- the list of procedures to be performed at this facility, immediately upon occupancy and potentially in the future. The specific procedures being performed establishes some of the code criteria in effect;
- anticipated staffing numbers per shift (for confirmation of parking stall counts); and
- specific accreditation requirements.
Overall, the facility was set up well for our client’s use. Wanting to take into consideration possible future challenges, we flagged code-mandated updates to the mechanical and electrical systems plus miscellaneous life-safety construction modifications involving fire-rated wall construction, exit signage and door construction types. The biggest hurdle was establishing the complete fire-rated separation between the ASC and adjacent clinic, including distinct waiting and reception spaces for both. Establishing this scope of work confirmed it was much more cost-effective to undertake the renovation of this former ASC than to start from scratch in another location. The client entered into their lease agreement and embarked on the renovations needed to provide a code-compliant space that meets the needs of their practice.
Now, let’s return to the client I mentioned in the beginning of this column, a nationally recognized digestive health expert looking at a car dealership for their new ambulatory center. This client wanted to expand their practice into new geographic areas. The building they were interested in was right on the outskirts of a booming retail and commercial area in what was becoming a major thoroughfare for the community. The location was perfect, even if the building was not. We first helped the client understand exactly what was needed to transform the building into an ambulatory center by surveying the facility and preparing a full report that explained what was needed and why. Considerations included:
- site improvements including re-grading around the building and parking lot, re-striping of stalls and drive lanes and an increase in handicap parking spaces;
- insulation and vapor retarder upgrades to the building enclosure walls, roof and window frame systems to account for the humidification being introduced into the building and for current energy code requirements;
- structural review and modification to account for structurally supported utilities, ceilings and equipment;
- introducing emergency power to the site,
- verifying existing water supply capacity was adequate for an ASC;
- providing medical gases on site; and
- installing a new sprinkler system to the building.
Despite all the hurdles, the location proved worth the effort and the client opted to proceed with the renovation. While not a driving factor, another bonus of this decision was knowing that one of the most sustainable choices is to reuse a building, leaving less carbon impact on the environment while simultaneously rehabilitating an existing part of the community. Upon completion, our client had a like-new facility that gave no hint to its previous function and, because it was a car dealership, ample parking.
Helping the healthcare client visualize the new use for this abandoned car dealership resulted in a creative revitalization of the space and a strategic investment in the community.
Regardless of where and how an ASC or ACC is being built, the same due diligence is required by the architect and provider to ensure the facility is designed and constructed properly. It is the architect’s responsibility to fully understand the building code requirements and the practice’s specific accreditation criteria by reviewing the International Building Code (IBC), National Fire Protection Association (NFPA), American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), Code of Federal Regulations, American National Standards Institute (CFR), American National Standards Institute (ANSI), Accreditation Association for Ambulatory Health Care (AAAHC) and other standards. The provider is responsible for early critical design considerations, including confirming the total number of procedure rooms and operating rooms desired, deciding whether preop/recovery bays will be open with curtains or private rooms, and how instrument reprocessing will be handled for the facility.
With any undertaking to retrofit, renovate or build a new healthcare facility, the stakes are high, but if done right, the return on investment can be a game-changer for the practice. “So, can it be done?” The answer is a resounding, “yes, it can,” and in a multitude of ways at that.
This article originally posted in ASC Focus, an ASCA Journal.