Like health organisations, hospital architects need to keep an eye on the big picture, the client’s vision.
For every stakeholder there will be a list of issues, the key drivers for success. Opportunities for cost effectiveness, quality issues, attracting and retaining staff, patient surveys that guide the hospital’s performance from a consumer perspective, reliable infrastructure, interaction with neighbours, and other considerations. More and more, in brownfield hospital projects, it’s about doing more with less.
Why Brown is the new Green
Almost inevitably, the start up meeting includes a suggestion to push it all over and start again. Healthcare providers, however, have a vested interest in making their built infrastructure work hard for them. It means they can focus their investments on tightening recurrent costs and updating equipment. The first clue is in a smart site strategy.
Greenfields offer a lot of opportunities, but . . .
Some say that if you build it all at once, you need to replace it all at once. The replacement cost of the built assets on the Royal Melbourne Hospital site is some $3-4 billion, so who wants to fund replacing this one? Over the years, we have looked at relocating it wholesale, moving services to the suburbs, pulling it inside out and rebuilding it piece by piece.
Staged redevelopment works for Royal Melbourne Hospital included, as a first priority, inpatient accommodation - but the challenge came in trying to determine where to put it. It was possible to include it in a stacked, generic form with a couple of floors funded at a time, but there was no shut down time for future stages.
Then there was the matter of how to extend the operating theatres and the need to consider the multiple other players on a major campus: the researchers, the staff support – they need to be close. The answer involved a carefully planned progressive barn dance where spaces were decanted out of the way, built and/or refurbished, then plugged back into the hospital chassis.
In regional areas, there is no other place to send patients during construction, so it is paramount that new components do not interrupt the patient, public and logistical flows of the existing hospital. Work should not be to the detriment of patient amenity. Key strategies for the Albury Wodonga Cancer Centre included building away from the main building, but connecting back in late in the project and placing wards next to wards wherever possible, offering long-term advantages for staffing and operational efficiency.
A key strategy for patient safety is standardisation. Question one is whether to match the old standard, or create a new one. It doesn’t take long for yesterday’s state-of-the-art to become today’s old practice. At Ballarat Base Hospital, we looked at the most popular of design discussions – the perfect ward:
• Start of a major vertical expansion on a space-constrained site
• Grid – 3x7 modules, projected up for future expansion
• New processes from research and experience
• Consider variety of cohorts
• New model of care and technology tools.
Test these in existing building, then build them in the new one.
Short-term pain (and rip the band-aid off quickly)
There is often a discussion on brownfield projects about staging and program. Most hospitals will suffer some short-term disruption if there is some longer term gain - a bit like ripping off a band-aid. This period of pain needs to be very carefully planned and managed – any extensions of time for these portions can leave the hospital business highly vulnerable.
For St John of God Berwick, some 13 stages of refurbishment followed the new component, as the hospital wanted to avoid any shutdown. This meant patients and doctors working around a construction site for the best part of a year. The lesson learned here was that larger areas of construction/fewer stages may have been a more successful outcome – it would have caused the same pain, but over a shorter period of time.
Design for the budget, the time frames and the site
The key success factors of a project are time, cost and quality. In brownfield projects, another factor needs to sit in this ensemble: the response to the site. In a brownfield, there is likely to be a number of constraints just waiting to be turned into opportunities. For the Mornington Centre, we called on the slope of the site to put the dementia ward on the first floor. This enabled privacy from the ground floor rehab program, and also enormous scope for outdoor spaces for training – learning to post a letter, wait for a bus, wandering, pacing. Sunny courtyards are intimate in scale and like outdoor meeting rooms, with seasonal gardens. These places respond to human needs, they are places for people.
Future proofing needs to be carefully considered for a brownfield project. It can be the difference between saving a bundle down the line or throwing money down the drain. Not every healthcare provider wants to invest in a masterplan document, but inevitably design discussions return to future expansion scenarios. Some kind of loose fit expansion strategy is required – an identification of potential growth avenues.
In the case of Werribee Mercy, the brief was to double the capacity of what was developed as a prototype single storey 120-bed community hospital, one funding batch at a time. As such, the first batch needed to cover a whole lot of infrastructure - planning for carpark infrastructure, electrical and other services infrastructure, and building infrastructure – like a new front door. The current “ground scraper” left little land available for development, so the future proofing strategy needed both horizontal and vertical expansion. Space for spare lift shafts was allowed for and the roof structure and façade system carefully detailed for effortless expansion in the future.