Health Facilities Management | Ambulatory Advice

Ambulatory Advice

Catherine Gow, August 2008 Download PDF

To capture more market share and increase referral bases, many hospitals are starting to build new outpatient facilities. Because outpatient centers provide patients with one-stop health care services where they can have a series of tests quickly, they often provide patients with an effortless experience when compared with visits to a main hospital.

Seven planning steps

As the popularity of outpatient facilities continues to grow, hospitals are grappling with the planning, design and construction of these structures. To help, here are seven steps that can guide hospitals through the process:

1. Identify the services.

When beginning to plan for a new outpatient facility, administrators need to first develop the list of outpatient services that will be included in the project. It is important to determine what services are required in the facility, as well as the services that will best attract customers. Most outpatient facilities include all or a combination of the following services: ambulatory surgery, cancer treatment, diagnostic imaging, phlebotomy, rehabilitation (including cardiac rehabilitation), sleep lab, and physician practices. Colocating similar programs at an outpatient center can achieve synergy between them.

An outpatient facility can allow medical institutions to expand their services, relocate certain services from the main hospital or provide specialized services in a single location. For instance, some hospitals are building outpatient wellness or “healthplex” centers that offer a range of programs that promote healthy lifestyles. The Atlantic Health Sports Institute in Florham Park, N.J., is a 100,000-square-foot wellness facility that includes an ambulatory surgery center, diagnostic imaging, a hyberbaric suite, outpatient rehabilitation and physician practice suites. The Atlantic Health System is building the facility as a joint venture with the New York Jets football team. The center will provide wellness and rehabilitation services for the sports team and the public. Both groups will have access to imaging and rehabilitation services as well as to the facility’s wellness components.

As the building program develops, some consideration should be given to amenities and support functions, such as food services or shared conference spaces. It is also important to consider basic administrative and support needs, which include IT and materials and delivery services. The staff of the outpatient center will need to have some way to communicate electronic information, such as patient records or diagnostic picture archiving and communications systems (PACS) images, back to the hospital. Because these decisions have financial implications, it is important that they are considered while planning for these services from the start.

2. Select the architecture and engineering (A/E) team.

It is essential for hospitals to find out how a consultant team will work with them and to determine their qualifications for a certain type of project. Full proposals from selected firms should include information about delivery methods, evidence-based design experience and information about key team members.

New technologies have introduced new methods of delivery. Firms should be able to provide files in a digital format using a form of computer-aided design (CAD). Moreover, some firms now use building information modeling (BIM) technology to deliver projects. BIM provides digital representations of a project at all stages of the process and simulates real-world performance, which can improve productivity and streamline construction. When BIM is used for a project, decisions must be made much earlier in the process and a greater percentage of the consultants’ fees must be paid up front. It a hospital is interested in using BIM, the selection committee should ask the architectural teams to tailor their submission accordingly, so they can compare design fees and schedules equally.

3. Set the design path.

Organization is the key to a successful outpatient facility. During the decision process, it is important to keep in mind that patients want easy access and quality service. By arranging the services in the style of a mall, patients can walk through the facility, learn about the full services offered and literally “shop” for health care.

Some of the services will require ground-floor access, such as cancer centers, which should be accessible to patients who may be weak and/or need extra support. It is also convenient to put quick, repeat services like blood draw and diagnostic imaging in ground-floor locations. Diagnostic imaging also usually requires a ground-floor location in order to avoid unnecessary structural costs associated with putting heavy equipment on an upper floor.

The size of the building footprint will also determine the arrangement of services. If the selected site can only accommodate a small building footprint, stacking the services can maximize space. It is important to think creatively about the arrangement of services because hospitals can actually save overall costs by moving certain services to upper floors. This is true of ambulatory surgery suites, for example, which have major ventilation requirements. Putting these services on the top floor allows direct roof access for HVAC, which can minimize ductwork and exhaust issues.

A hospital can boost interest in an outpatient facility and its services by including a large conference room or a conference center, which can be used for community events or rented out for meetings. Such amenities offer a way for hospitals to further their services to the community and increase awareness of the kinds of services they provide.

4. Balance expectations.

It is best to discuss and manage expectations early in the project to ensure that the end product meets the desired goals of the hospital and its patients. An architect can bring expert advice and help guide the client through the design and development of the exterior and interior elements of the building. Bringing a construction representative into the design process early on ensures that the construction team will be aware of the key design elements such as high-end lobby finishes, atria and clinical fixtures, as well as additional HVAC requirements for medical services.

It is easy to lose sight of these kinds of issues during the value engineering process if the individual items have not been clearly understood by the entire team before the elements of the design have been priced. One example is the design of Main Line Health System’s Bryn Mawr Health Center in Newtown Square, PA. At the start of the project, the contractor, the hospital, and the architectural team met to discuss such key design issues as canopies, entry enclosure materials, egress stair placement, parking counts, and lobby finishes.

They also discussed the program components, including a cancer center, which required a separate entrance canopy to give it visibility, although that was not originally included in the project budget. The team found a cost-effective solution by placing a distinct canopy for the cancer center along the main entry sequence. This would have proved a difficult assessment without the contractor on board to provide adequate pricing.

A hospital also may want to engage the community and local physicians to get their feedback and capture their buy-in on the project. Community sampling can also inform the process. This can be done in several ways, including a large open-house meeting, a smaller invitation-only meeting or a survey.

5. Develop a basis of design and a cost estimate

A basis of design is a tool that sets the design parameters for a project and it should be used every time to keep the process on track and ensure a high-quality outcome. Typically developed at the end of schematic design phase, it is the primary document that translates the owner’s needs into components such as a building envelope, HVAC systems, security systems and specifications including anticipated finish levels. It also describes the technical approach planned for the project. This written document is produced by the A/E team and typically delivered to the construction representative along with the schematic-level package for pricing. A basis of design guarantees that all parties share agreement about design decisions and fees. When a basis of design document was produced for Mercy Health System’s Fore River Medical Pavilion in Portland, Maine, it allowed the develop to accurately price the building. The final costs was held to within 5 percent of the original estimate.

The initial cost should include any customized features, such as special finishes, that give the clinical setting more of a hospitality-oriented ambience. It should also include pricing for telephone systems, data, and security. A separate estimate for furniture, fixtures, equipment and signage should be compiled. It is most effective to include these costs up front rather than later in the project. This will prevent the hospital from having to remove amenities and high-end details later.

6. Maintain design and branding goals.

During the design process, the architectural team is responsible for making sure that selected details and customized features match the actual end product. It is beneficial to keep the architect involved in the process, even in an advisory role, until the project is finished to maintain consistency throughout the building. This is particularly true if a hospital wants to further its branding strategy by matching the look and feel of an outpatient facilitiy to its main hospital. For example, the Main Line Health System wanted to exten its branding strategy when it built Bryn Mawr Health Center. It was important for the hospital that the image of the building be consistent with its original medical campus. During the design process, the construction team met frequently to discuss the building’s aesthetic. This informed the process and kept all parties on board as major decisions were made.

7. Coordinate all decisions to deliver a fast, seamless project.

Speed is always an issue, as scheduling delays can increase costs. To deliver a project on an accelerated schedule, the architect will need to submit early packages for fast-track delivery of the foundations and steel. Sending these packages out earlier than the rest of the design documents will speed up the schedule and allow for earlier occupancy. This can be especially helpful for longer lead items, such as HVAC units.

The price of oil and the pace of global development have put a greater premium on building materials, which means that the costs of materials is almost certain to rise during the course of a project. However, hospitals can take steps to minimize costs overruns. When the Mercy Health System of Maine was building the Fore River Medical Pavilion, they asked the developer and the architect to hold firm to a 14-month construction schedule. The developer was able to prepurchase many of the most expensive building materials, which allowed them to minimize escalation of the project cost.

It is best to make early decisions with vendors wherever possible. Although it makes financial sense for most hospitals to purchase major medical equipment late in the project, this becomes a challenge for architects and engineers because they must accommodate the size of the equipment and coordinate all electrical and mechanical issues.

To keep the project moving forward, many facility managers may advise the architect to utilize the generic installation documents typically supplied by vendors. However, this type of process may incur additional fees, changes and time until a vendor is locked in, as electrical conduit locations and structural needs can vary.

As hospitals become increasingly consumer-driven, patients will be attracted to facilities that can provide them with the best service and the most comfortable and convenient environment.

By following these careful steps, hospitals will be able to create spectacular outpatient facilities that provide quality treatment and easy access.


Catherine Gow, AIA is senior health care planner at Francis Cauffman Architects, Philadelphia. Her e-mail is


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