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3 important trends in hospital design that Healthcare Giants are watching closely

BD+C’s Giants 300 reveals top AEC firms in the healthcare sector.

July 20, 2012 |
OR suite in the 465-bed Kaiser Permanente Los Angeles Medical Center. Phase 2 is

The healthcare sector faces grave financial uncertainties, even with the June 28 Supreme Court decision upholding the Affordable Care Act. To help us sort out the factors impacting this lucrative segment, we turned to Philip Tobey, a Fellow of both the AIA and the American College of Healthcare Architects and Senior Vice President with SmithGroupJJR.

“Health industry providers legitimately expect significant efficiencies and lower costs for design and construction services, to go along with the economies that they themselves face with tighter and value-based reimbursement terms under health reform,” says Tobey, a member of Building Design+Construction’s Editorial Board.

In other words, AEC firms are going to have to share some of their healthcare clients’ pain. The drive for greater operational efficiency and lower cost in healthcare will be unrelenting, with bundled payments and shared savings models in lieu of traditional fee-for-service reimbursement forcing healthcare providers to eliminate wasteful practices.

Tobey sees three major trends emerging: 1) growing emphasis on ambulatory care, 2) medical systems integration, and 3) the “bundling/unbundling” of services.



“The trend to push services out of the hospital into ambulatory settings will only intensify,” says Tobey. He notes, however, that there will be an “overwhelming need” to expand the front end of delivery—primary care, urgent care, and emergency departments—and to rationalize procedural and imaging resource capacity. At the same time, freestanding surgery and imaging centers may not be as prevalent in the future, and may need to be consolidated into larger hospital centers.

“Hospitals are not going away,” says Tobey, even though inpatient volumes are predicted to fall 5%, vs. 30% growth in outpatient volume. The sheer increased volume of patients, especially as baby boomers age, will inevitably drive up acute-care admissions. In the face of these seemingly countervailing trends, says Tobey, “The need to renovate outdated or obsolete facilities will be a strong driver in the healthcare business.”


Tobey says the need for greater efficiency and ever-higher quality of care are not new goals for medical care or medical design, but hospital systems are being encouraged further by healthcare reform to streamline processes, with more mergers, acquisitions, and hospital-physician staff integrations on the horizon. “The industry’s even been talking about including services like long-term care and home care into this integrated approach,” he says.

Although there will always be a need for acute-care hospitals, Tobey sees a possible shift toward more community-based portals. As health systems continue to integrate, they will rely more and more on treatment venues outside the hospital to provide patients with coordinated preventive care and treatment for chronic conditions.

The IT component of hospital systems is already a natural for systems integration. “Providing the right information where it’s needed is essential for clinical care,” says Tobey, who foresees greater implementation of electronic medical records.

Are hospitals ready for lean?

“Everybody’s talking about it, but many hospital owners are wary of taking on lean,” says SmithGroupJJR’s Phil Tobey, FAIA, FACHA, whose firm is on the team for Sutter Health’s California Pacific Medical Center in San Francisco, the largest lean project in the U.S. “You have Sutter, which is totally lean, then you have clients who tell us not even to mention the word,” he says. “Others are applying the basic principles of lean construction without carrying the heavy weight of all that lean entails.”

Applying Lean/Six Sigma principles to healthcare, says Jeffrey C. Stouffer, AIA, a Principal with HKS, would result in “measurable outcomes and even risk sharing as part of the design and construction process” by eliminating unnecessary waste in construction and operations and increasing staff efficiency and safety, while reducing energy and staff costs for the hospital.


Healthcare providers are “decanting” non-core functions—services like pharmacy, lab support, materials handling, and environmental management—from the mother ship into cheaper B-occupancy buildings. “Anything soft, anything that’s not high-tech, is being taken out,” says Tobey. “That’s the unbundling.”

However, once the unbundling of less-intense services has been accomplished, says Tobey, some hospital systems are opting to bundle the remaining hospital space, by placing beds back on top of the structure’s base diagnostic and support block, instead of having the traditional diagnostic/support chassis with attached nursing wings.

“You unbundle and decant the support services, then take the remaining high-intensity hospital base and put the beds on top,” says Tobey. A recent study for a 100-bed community hospital found that following such a scheme would result in 39% savings in construction costs per bed. +



Rank Company 2011 Healthcare Revenue ($)
1 HDR Architecture 205,200,000
2 HKS 124,736,964
3 Perkins+Will 122,895,589
4 Cannon Design 121,000,000
5 NBBJ 116,401,000
6 HOK 102,695,248
7 SmithGroupJJR 74,600,000
8 RTKL Associates 68,421,405
9 Perkins Eastman 63,700,000
10 Hammel, Green and Abrahamson 61,900,000
11 ZGF Architects 54,338,355
12 Heery International 48,583,000
13 HMC Architects 42,715,899
14 PageSoutherlandPage 38,670,000
15 IBI Group 37,349,554
16 Skidmore, Owings & Merrill 33,950,000
17 FKP Architects 33,947,200
18 Gresham, Smith and Partners 32,876,981
19 FreemanWhite 28,500,000
20 RBB Architects 28,500,000
21 LEO A DALY 26,900,325
22 BSA LifeStructures 26,323,759
23 EwingCole 24,000,000
24 KMD Architects 20,161,678
25 Ennead Architects 19,875,000



Rank Company 2011 Healthcare Revenue ($)
1 AECOM Technology Corp. 314,000,000
2 Stantec 109,980,000
3 URS Corp. 41,298,918
4 Smith Seckman Reid 38,300,000
5 Jacobs 32,950,000
6 Parsons Brinckerhoff 30,600,000
7 KPFF Consulting Engineers 28,000,000
9 Mazzetti Nash Lipsey Burch 24,988,296
10 Degenkolb Engineers 22,454,591
11 Allen & Shariff 21,577,769
12 Bard, Rao + Athanas Consulting Engineers 18,000,000
13 ccrd partners 17,100,000
14 Atkins North America 16,173,240
15 AKF Group 15,200,000
16 KJWW Engineering Consultants 14,607,369
17 Syska Hennessy Group 14,462,238
18 Zak Companies 13,882,705
19 TLC Engineering for Architecture 13,874,283
20 Dewberry 10,613,564
21 Thornton Tomasetti 9,860,000
22 Sparling 9,658,825
23 Walter P Moore 7,718,326
24 M/E Engineering 7,700,000
25 Rutherford & Chekene 7,650,000



Rank Company 2011 Healthcare Revenue ($)
1 Turner Corporation, The 1,807,050,000
2 McCarthy Holdings 1,231,000,000
3 Gilbane Building Co. 1,091,777,000
4 Clark Group 1,067,411,678
5 PCL Construction Enterprises 869,130,091
6 Brasfield & Gorrie 833,522,003
7 Skanska USA 724,418,042
8 JE Dunn Construction 636,206,095
9 Robins & Morton 599,073,000
10 DPR Construction 588,199,172
11 Whiting-Turner Contracting Co., The 464,779,240
12 Mortenson 455,620,000
13 Lend Lease 434,626,482
14 Hensel Phelps Construction 425,760,000
15 Suffolk Construction 420,343,563
16 Pepper Construction Group 415,064,000
17 Tutor Perini Corp. 409,583,000
18 Balfour Beatty US 389,253,907
19 Hunt Construction Group 369,500,000
20 Hoar Construction 313,937,000
21 Flintco 291,400,000
22 Layton Construction 287,300,000
23 HBE Corp. 279,200,000
24 Power Construction 275,000,000
25 Swinerton 274,627,440
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