This is the second article in a series by Jon Huddy, ED architect and author of ACEP’s ED design book, offering insights to you as an ED physician leader on how to position your emergency department for architectural design success.  The previous article focused on positioning yourself to be placed on key committees that will be making impactful decisions on your potential ED project.   This article focuses on the three major components of priorities, scope and budget that will impact your future ED design for the next 20 years.

Early Meetings

Let’s assume that you have positioned the ED to be considered and authorized for a renovation or expansion project.  Instead of sitting back and waiting for a successful project to be designed, you need to make sure that you are a part of any initial discussions regarding “next steps.” No organization sets out to deliver an unsuccessful architectural project, but initial meetings and early planning decisions can impact a final construction project (positively or negatively) that may be years away from being completed.

Planning vs. Design

The terms for project “planning” and “design” may seem the same to you as a clinician, but they have very different meanings in the world of architectural construction projects.  Let’s start with the latter, “Design.”  Design is considered the detailed shaping of a project within the allocated space available within the established project budget, whether the project be on a new site, expansion of and existing ED, or interior renovations of your current ED.  In summary, “design” is the task of creating a physical solution within the established parameters that have been set for a project.

Planning,” on the other hand, is the work completed prior to design and is focused on establishing the parameters within which the team will  design a final solution.   It’s the initial planning associated with the analysis of your current operational patterns; future volume expectations; future patient types and acuities; and subsequent facility needs that will, in turn, establish the size and budget parameters for your future project.   Your organization may refer to this early “planning” as master planning, scope definition, or feasibility studies.  In any case, keep an ear out for any information that may infer that people are reviewing potential “planning” parameters or scenarios for your future ED.   As stated in the previous article in this series, you may have already positioned yourself to be on this planning team.  However, if you haven’t, you need to make sure you keep abreast of any planning work being considered or completed for a potential ED project.

You should involve yourself in early planning to establish the following three components that dictate the parameters of your future design:

Priorities

Setting priorities for “what” you need expanded or redesigned is very important with regards to setting an ED project on the right path for success.   Someone outside the ED, such as a Facilities Director, Vice President, or COO, might assume you “just need more exam rooms.”  And, most likely, that may be part of a future solution.  But, you may also know that your “upfront” triage area doesn’t support your vision of a “care initiation” area with space and support for advanced protocols, vertical stretchers, inner waiting area, etc.  Or, you may know that imaging capacity is a major bottleneck for you.  Imaging might not be integrated into your ED and you are still at the mercy of the imaging department to come retrieve patients, take them to the imaging department, and return them to the ED… all of which adds to delays in length of stay time.  In any case, the priority of integrating or expanding ED imaging components may rise to the surface.  If you are involved early in the planning process you can assist, or lead, in the development of setting priorities.  Some of which may be:

  • Additional exam room capacity
  • Patient and family amenities
  • Additional resuscitation room capacity
  • New areas for vertical, rapid care, or protocol areas
  • Inner waiting / results waiting / discharge staging areas
  • EMS staging / protocol areas
  • Imaging components added to, or expanded within, the ED
  • CDU / Observation capacity
  • Teaching spaces inside, and outside, the main clinical area
  • Work areas for clinical teams / providers
  • … and what feels like another hundred priorities

My point is that you shouldn’t let others set your priorities.  As you get involved in analyzing and finalizing your priorities, then this work will immediately lead you to the next component that will shape your successful project: Scope.

Scope

The “scope” of a project may include many different considerations.  Simply put, some people refer to scope as “how much area” will be added or renovated.   A more expansive review of scope may be “do you renovate and expand or completely relocate the ED to a new location on campus?”   Your early involvement will stop people from just assuming “if we give them 15% more space that should be enough for some new exam rooms.”  Again, that extra space might be a part of a final solution to meet your needs, but the size/scope of a project needs to consider many more issues before assuming an additional “X” amount of square footage will be “all that you need.”    (See future article on “Understanding Square Footage.”)

As you venture into defining the “scope” of a new or renovated ED, you should step back and forget about “square footage needs” altogether.   Start by focusing on future operations, lean workflow patterns, the patient experience, and the expectations of staff and providers.    I have worked with many ED groups and while they may dream of a better future it is often difficult for staff and providers to forget about the current obstacles they encounter every day and look to a new (operational) future.

You need to clearly define your future vision for moving patients through your ED “system,” establishing what your expectations are for an excellent patient experience, and defining how ED staff and providers will deliver efficient, modern, safe care.  Only when your future vision is clear and you know what operational patterns you expect the ED to support in the future, can you start to define the true physical design needs for a successful architectural project.

You should also involve yourself in the “future utilization projections” work that will establish a design target for how much ED volume the future ED will need to accommodate.   Your organization may have in-house market analysts or they may use an outside consultant such as Huddy HealthCare Solutions.  In any case, make sure your voice is heard regarding future volumes.   Your input is especially important in this era of the Affordable Care Act and how you believe ED patient volumes will be impacted in the future by the ACA, rising acuities and an aging population.

A final component of “scope” definition is the impact on “make ready” projects that need to initially occur prior to getting to the actual ED project constructed, and I cover this component in the last section of this article.

So, getting involved in setting the scope of a project is a large undertaking, but I have assisted many ED physician leaders through the “scope definition” phase of a project and it is a great experience to see the inventiveness and innovation that comes from each ED clinical user group team as they start to envision a better future.   While I don’t have space in this article to address the hundreds of considerations that support a better future in a new or renovated ED, I can tell you that, in the end, every project “scope” will end up being evaluated for “cost versus benefits” delivered.    Which brings me to the third major component that you will need to make sure gets your attention as soon as possible: Budget.

Budget

Budget, the old Bottom Line.  Yes, it always comes back to the bottom line of project budgeting and the capital your organization has available to invest in a new or renovated ED.   I am not recommending that you become an expert in renovation costs, construction costs, contingencies, or project financing.  But, I am asking you to maintain working knowledge of the project budget and how it will affect your project priorities and size (scope) of a project that can be delivered.

Budgets are either established “top-down” or built “bottom-up.”  By “top-down” I mean that an organization starts by immediately establishing a quantified capital budget and lets everyone know that you have to prioritize what you need and deliver a project within this pre-established dollar amount.  A budget that is developed from the “bottom up” means that you start with a clean slate, evaluate true needs, quantify space needs, establish a scope, and then create a comprehensive budget based on these needs.   Now, I will warn you (and I am sure that you already know this) that no project has ever had a “green light” to develop a budget that will cover as much space, technology and equipment that you will ever need in a future ED to cover 20 years of growth.   So, somewhere along the line, a budget number will be established that you will have to work within, it’s just that some organizations cap that budget immediately (top-down) and some organizations wait to see what your true needs may be prior to establishing any capital constraints.

With either a top-down or bottom-up budget you need to be clear on “what” is within your budget.   Previously, I mentioned defining your priorities and the subsequent “scope” of a project all of which focused on your emergency department.  However, there are many things that may need to occur over the course of a construction project that will impact the final budget allotted to the emergency department.  Let’s consider a fictional scenario that in order to gain the amount of area you need in your future ED (to accommodate your proposed workflow, technologies, and estimated future patient volumes) that you will need to complete the following phases to implement your ED construction project:

  • Expand ED space into an adjacent, existing department that will be relocated (for example, let’s assume it’s Materials Management storage space).
  • You also need additional square footage (over and above the Materials Management space) and thus need a building addition to expand the ED into the existing parking lot.
  • And, in the end, you are going to go back into your old emergency department and completely renovate this space so that all components (expansion into Materials Management, new building addition into the parking lot, and renovation of current ED) all flow together for a single, expanded, efficient, flexible emergency care environment.

Now, let’s assume that your top-down budget was previously established at $18,000,000.  So, in your mind you have $18M to “expand the ED” and that sounds like a lot of money.   As you start to define how the budget will be spread across the entire project you may find (for example only) the following consequences:

  1. The cost to relocate Materials Management is going to be $3,000,000 because the space it is being relocated to doesn’t meet current building codes for storage space and a great deal of the $3M will be to upgrade the new location to current design guidelines.
  2. Your budget establishes the cost of renovating the old Materials Management space into new ED space at $4,000,000.  (At this point, you are $7M into your $18M budget).
  3. The renovation of your current emergency department is going to trigger new codes for heating, ventilation, and air-conditioning (HVAC) requirements so $1,500,000 will have to be spent on upgrading engineering infrastructure as part of the renovations, and this doesn’t include the actual cost to renovate the old ED into new, upgraded clinical space.
  4. The cost to renovate the current ED and change the architectural environment is established at $6,000,000.  (At this point you are $14.5M into your $18M budget)
  5. The building expansion into the parking lot results in having to move an underground decontamination tank, water lines that service the hospital, and sewer lines meaning that $2,000,000 will be spent on just preparing the site for the new building addition, not including the cost of any new ED construction.
  6. The building expansion is going to expand into the parking lot and the result is that you lose 30 parking spaces.  The cost to replace these parking spaces means that your organization has to purchase an adjacent property to add the lost parking spaces back to your parking total to meet minimum city parking codes.  The cost of buying the property and replacing the parking will take an additional $1,500,000.
  7. Now, at this point, you have already allocated $18,000,000 of an $18,000,000 budget limit, and you haven’t even built the new building addition.   And, you can’t afford any new equipment or technologies in the ED because the entire budget has already been allocated.

So, the original $18M budget sounded like a lot of money at the beginning of the project, but in the end, the scope of the project included outside costs that consumed your entire budget.   In a case like this it means you have to go back to the drawing board to define a project that can be implemented within the set budget.  Options may include not moving materials management (saving $7M), limiting renovations in the old ED, and focusing more of the budget on the outside building expansion.

My advice to you as you start to work on defining your priorities, setting a project scope and working with people within your organization to develop a corresponding budget, is to make sure you are clear on the preliminary phases being considered for “make ready” projects.  “Make ready” means all the projects (and costs) associated with preparing a building or site for an ED project.  The above example includes make ready projects for moving Materials Management, civil engineering work underground on the expansion site, purchases of new property, the cost to replace parking, and the upgrading of engineering infrastructure to renovate the old ED.   While you don’t need to be a professional construction estimator, you should push the leaders in your organization to be clear on what is being considered “make ready” costs versus the budget for “the new ED.”  By being on top of how the budget is being distributed it positions you to make better decisions on various options for renovating and/or expanding the ED.

Hard Costs vs. Soft Costs

You should also be aware that hearing a budget amount may not mean that the entire amount is going to construction.   When you hear a budget amount being stated, your first question should be “is that a construction cost or a total project cost?”

Construction Costs (referred to as “Hard Costs”) include the actual money that will be spent on the materials and labor to build a project.   This is the “bricks and mortar” of a project, and includes everything it takes to actually construct the building or renovate the existing space.  Construction/hard costs also include the cost for engineering infrastructure systems and the costs associated with site work such as parking, roadways, landscaping, etc.

Soft Costs” include the equipment, professional fees, contingencies (to cover unforeseen conditions), and other related items that it takes to get a final project completed and operational.   In some instances, the “soft costs” may make up 40% to 50% of a total project budget.  Think of a smaller construction project that might include $4M worth of CT and Imaging equipment in the new addition.  The costs for adding that equipment may be half of an $8M total project budget.

“Total Project Cost” includes the hard/construction cost plus the “soft costs” and is considered the entire amount it will take to get a project completed and up and running operationally.   So, next time you hear “we have a $10M budget” make sure you know how much is being allocated for actually construction, make-ready projects, and “soft costs” to outfit the new ED space!

Understanding Square Footage

My next article will help you understand the various ways square footage is calculated on an ED architectural project so that you are prepared to discuss and discern how a proposed “size” of a project will actually deliver “new space” to your emergency department.

Please contact Jon Huddy directly should you have any questions, comments, or would like any additional information on the topic of positioning yourself for a successful role and final outcome with regards to an ED design project.

Jon Huddy can be reached at (803) 517-7522 or j.huddy@huddyhealthcare.com

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