Breaking up with the mega hospital: Redefining healthcare campus master planning in Canada
November 11, 2024
A refreshed phased campus model for hospital development offers many benefits
For decades, Canada¡¯s provinces have expanded healthcare by building new, large, multifaceted hospitals. The ¡°mega hospital¡± promises everything you need in healthcare in one building. The expansive, all-in-one facility offers collaboration, shared resources, and integrated care. But now, an alternative is attracting interest. It¡¯s the phased healthcare campus model.
Let¡¯s talk about where we are.
Recently, the costs of hospital construction have skyrocketed. Hospitals that were built for under C$600 per square foot in 2017 are now coming in at over $2,500 per square foot. With an average size of more than 1 million square feet, a mega hospital¡¯s total price tag starts at $2.5 billion. A recent mega hospital in Western Canada was paused when an early estimate pegged the project at a whopping $5 billion.
A confluence of factors has contributed to the hyper-inflation of heath construction costs. Ripples from the pandemic¡ªsuch as increasing cost of labor, materials, and finance¡ªare part of the problem. There is an increasing desire to transfer design and construction risk from the owner to the design-builder. And that, coupled with substantive changes to the insurance and bonding markets, have also helped drive up costs.?
Bannatyne Campus Master Plan in Winnipeg, Manitoba. (Image courtesy of Shelton Foo/ooee studio)
The size and cost of these projects does not promote competition. Securing a construction bond, which protects against disruptions or financial loss, is not easy on projects of this scale. Very few general contractors or consultants in Canada can even qualify to bid for these multibillion-dollar mega hospitals. Breaking these projects down in size would allow for more competition and possibly drive down costs.
The sky-high price tags make large hospital projects more contentious. Community groups and voters are raising questions about the cost and sustainability of this type of project. Because they are funded through community fundraising and government allocation, they can be hard to finance. But all of this is changing.
Rising costs have prompted a rethinking of mega hospitals in Ontario. The healthcare campus model of master planning is gaining ground.
A refreshed model for hospital master planning in Ontario
A healthcare campus phased model for master planning hospitals is emerging. And it is already informing our hospital designs in Ontario.
This healthcare campus model phases the hospital development into a series of smaller packages. Right now, we are designing and constructing a single massive building all at once. With a different approach, we break the hospital program into several smaller, individual buildings. These are intentionally constructed over time. For example, the first phase can consist of the emergency department and the ambulatory care center, energy center, and parking solution. The second phase could include the inpatient tower. The third phase is diagnostics and treatment. And in the fourth phase, a complex care unit.
In this phased, healthcare campus model, we can design and deliver hospital projects piece by piece. They are sustainable, flexible, and responsible.
We often work on large-scale hospitals, so we have been looking into this phased campus for a while. Now a provider we work with has had a similar idea for a multisite hospital project. It was originally presented as a mega hospital concept to bring together all services and specialties under one roof. But the Ministry of Health in Ontario encouraged the provider and the design team to break it down into phases. The goal? To manage costs and encourage competition in the construction stage. Challenged to rethink the original design brief, the team reimagined the project as a multiphase, multibuilding deployment. The Ministry references that multiphase approach as a master plan solution for other organizations that were previously considering a mega hospital.
This healthcare campus model can reduce the initial capital cost and time required to start delivering care. It can benefit both patients and caregivers. It will allow health systems to accommodate changing needs and technologies over time.
Bannatyne Campus Master Plan in Winnipeg, Manitoba.?
We are currently supporting over a dozen hospital systems across the country in master planning their campuses. Our clients are looking for solutions for responsible development. In many cases, we suggest that their best option is a campus-style master plan executed in phases.
There are three big reasons why. First, it¡¯s responsible. Second, it¡¯s flexible. And third, it¡¯s sustainable. Let¡¯s look at each of these.
Responsible: Greater competition and more facilities
This phased healthcare campus master planning approach is socially and fiscally responsible. Breaking up the project construction into smaller, decentralized elements can help control costs. It allows more small businesses to participate in the marketplace and bid on projects. More bidders on smaller campus projects can increase competition and cut the overall cost per square foot of the project. Increased competition could mean that four 250,000-square-foot projects will cost less than one that is 1 million square feet.
This healthcare campus approach also decentralizes investment in healthcare. It allows the authorities to invest in expansion and renovation of healthcare facilities in more places. Why? Because a huge budget is not committed to a single large project. It should allow us to build more healthcare facilities in more areas.
And it changes the site-selection conversation. We can consider diverse types of parcels than we might for an extremely large all-in-one hospital. We may be able to create new master plans for existing sites this way, rather than looking at greenfield sites. Some of these spaces may be able to benefit from simpler construction methods as well. For example, in one British Columbia project we noticed that the academic teaching portion of a new hospital did not need to be built to the same resiliency standard as the rest of the facility. We were able to reduce costs by making this academic space an adjacent standalone structure.
Healthcare spending is precious, so we must spend wisely.
Flexible: Unique solutions for each community
This approach promotes flexibility. It enables the hospital to phase the campus development according to its needs and priorities. It allows it to adapt to changing clinical needs, medical technologies, climate, and other demands. While it might seem that this phased approach resembles a traditional hospital system that grows and adds buildings as its needs expand, it¡¯s very different. This planned approach allows the hospital to grow over time and address urgent priorities first.
Rising costs have prompted a rethinking of mega hospitals in Ontario. The healthcare campus model of master planning is gaining ground.
We can master plan the hospital and strategize its phases so that the result is an efficient and flexible whole.
For example, on one of our healthcare campus master plans, we designed the new flexible infrastructure backbone to support multiple phases of the future build-out. The new central utility plant and central parking, constructed in the first phase, can accommodate new buildings and equipment as required. In this way, we can right size and plug in equipment upgrades when we have greater certainty around changing functional needs and climatic conditions. This modular plan allows the healthcare institution to add as it goes, for decades.
This allows each phase to be built to the latest codes and standards, which change over time. It also allows us to group programs so that some phases can be built as medical office or support buildings.
Each client is unique. They have their own way of operating a hospital and delivering care. This phased healthcare campus model allows designers to refine and improve the design and processes of the hospital through post occupancy evaluations. Hospitals can study what works best in the early phases and design those into the next building.
This flexibility also means we can use existing, older hospital buildings for lower-acuity programs. These might include administrative areas that don¡¯t have the same space and service needs. We can plan to build high-acuity programs, such as operating rooms and inpatient beds, as a new addition to an existing building. The reused building serves the lower-acuity programs while the new structure houses the high-acuity programs.
Sustainable: Building reuse and rightsizing
Why is a phased campus approach to development sustainable? It can reuse existing buildings, reduce carbon emissions, and explore other design and construction innovations.
According to the Canadian Medical Association Journal, the health sector generates more than 4 percent of Canada¡¯s total carbon emissions. Health campus master planning gives us additional ways to reduce the carbon footprint of new healthcare facilities.?
Penn Medicine¡¯s Cherry Hill Medical Office Building in Cherry Hill, New Jersey. The design repurposed a big box store into an outpatient care center.
The reinvention of the master plan also creates bite-sized projects. Smaller-scale projects have a better chance of fitting within our existing building stock. Adaptive reuse of existing buildings, while often challenging, can help us mitigate the embodied carbon invested in a new healthcare complex. In the US, we have been able to repurpose big box stores to outpatient care centers (as we did on the Cherry Hill Medical Office Building in Cherry Hill, New Jersey) at a fraction of the cost of a new build solution.
These healthcare campus master plans can take advantage of efficiencies of district energy. These projects can help transition communities into the energy-sharing economy. Swedish Health Services in Seattle, Washington, recently created a decarbonized central thermal energy plant. The plant cools the growing hospital campus and sends its waste heat to adjacent communities through a district energy system. Community centers often place ice rinks next to pools to use the waste heat from the rink to heat the pool. A hospital can work in a similar way as a source of hot water and heating for nearby residential communities.
The healthcare campus approach also gives us flexibility. We can use innovative approaches on the project elements rather than applying a single approach to an expansive project. For example, we can use a modular construction approach to building. Studies show that modular and prefabrication solutions can reduce the embodied carbon on these projects by 15 percent.
Healthcare campus model
With climbing costs to create mega hospitals, it¡¯s time to rethink how hospital campuses are planned.
An updated phased healthcare campus model for developing large-scale healthcare projects offers many potential benefits. We believe that projects that take this approach could be more responsible, flexible, and sustainable.