By Roger Hartung, AIA, NCARB
Imagine finding out that your Labor & Delivery Department is going to experience a 156% increase in births in the next year. And, as if that isn’t enough, you quickly realize that adding that kind of additional volume to your existing department that rapidly will be all but impossible.
Forbes Hospital in Monroeville, Pennsylvania had exactly that realization soon after signing an agreement with a new obstetrics practice. Knowing it was imperative to expand the Department and satisfied with their team’s recent performance, Forbes immediately engaged IKM Incorporated as the architect for the expansion, and soon after, MBM Contracting as the Construction Manager. Executing project delivery through the fast track method – i.e., beginning construction operations prior to completion of design – was the only way to complete this project on time.
Benchmarking from the Advisory Board
Programming and preliminary design work began in October of 2015. IKM and Forbes Hospital reviewed past occupancy rates of the existing Labor & Delivery Department. “IKM provided national benchmarking occupancy rates for Labor and Delivery Departments from the Health Care Advisory Board,” said Mark Rubino, MD, Chief Medical Officer at Forbes Hospital. “We compared those to our prior years’ rates to determine our planning and programming space needs.”
The existing Labor & Delivery Department is on the fourth floor of Forbes Hospital. Options that moved the entire Department elsewhere were reviewed and rejected due to cost and schedule. Interestingly, the quickest and most cost effective plan was to expand services where they were currently located. A major challenge with this approach was that the remainder of the fourth floor was not available. One of the busiest medical/surgical units in the Hospital occupied the space.
The existing department operated with a Labor Delivery Recovery & Postpartum (LDRP) room model that included a few Postpartum Rooms to accommodate spikes in demand. For Forbes, one of the most effective ways to address increased volume was to go to a Labor Delivery Recovery (LDR) room model with a sufficient number of Postpartum Rooms to handle the added capacity. In the past, the Hospital had struggled with patient satisfaction when mothers were moved to smaller Postpartum Rooms. The Hospital determined that in order to transition to an LDR model, new Postpartum Rooms would be designed that were on par in style, amenity and size as the existing LDRP rooms. The decision was made to create ten Postpartum Rooms at a quality level of the existing LDRP rooms. Increasing the capacity of other components of the Department were reviewed and adjustments were made to equipment storage, nurse stations, staff areas, meds rooms, on-call rooms, and clean and soiled rooms.
Achieving Design Intent
“Our design intent was to bring together the comforts of home with the details of a boutique hotel in a room that new mothers hope to be transferred to,” said Samara Wheaton, Interior Designer for IKM architects. She added, “New mothers should feel like they are at home, with an increased room size, more spacious toilet rooms and added family areas so all family members are able to feel comfortable. The increase in the room size also allows for moms and their new babies to room together comfortably.”
The existing department has a Cesarean Section delivery suite with a single room for such procedures. Adding a second C-Section room would add time and money to the project, therefore, the value of this option had to be carefully reviewed. Fortunately, a new patient-transport elevator project was under construction, also designed by IKM. Though a stop on the fourth floor within the Labor and Delivery Department was planned, an LDRP room would have to be removed in order to make the elevator connection. This removal was not part of the elevator project. Creating the stop on the fourth floor would allow mothers who presented in the Emergency Department (which is where all off-hours mothers presented) to travel directly from the Emergency Department to Labor & Delivery. This elevator also would allow direct access from Labor & Delivery to the Surgery Department. Creating the connection on the fourth floor would eliminate having to build a second C-Section room. Mothers could be quickly transported to an operating room for a C-Section, if necessary.
An additional challenge that the program faced was that the new Obstetrics Group would increase the catchment area of births for the Hospital. This meant that the likelihood of an expectant mother being sent to the Hospital by their physician would increase for safety reasons due to the travel times of many of the expectant mothers. This added volume increased the need for triage rooms. Since new, larger Postpartum Rooms were being created, the determination was made that three of the existing Postpartum Rooms could be utilized as triage rooms.
Relocation of the medical/surgical suite on the fourth floor adjacent to Labor & Delivery still had to be solved. Other projects were concurrently in construction within the Hospital. If a solution could be found to insert the medical/surgical unit elsewhere as other moves happened, the space required for the expansion of Labor and Delivery could be made available. A Step-Down unit was about to relocate into a recently renovated space that was formerly an ICU. The ICU was no longer needed due to the construction of a new ICU elsewhere in the Hospital. IKM recommended that the Med/Surg unit on the fourth floor would be given priority to relocate there. To avoid adding significant time to the schedule the scope of work, the existing unit would have to be limited to receiving little more than a paint job. Additionally, the actual move of patients and equipment had to be well orchestrated. Nursing staff would need to be increased temporarily during each move.
Operational 2 ½ Months after Programming
With programming complete and acceptance of moving the medical/surgical unit gained, IKM’s proposed floor plan obtained approval from the Hospital on November 11, 2015. Now the hard work would begin in earnest. IKM with its decades of experience in healthcare design understands that the thought and design that has to go into a set of construction documents involves far more than just a basic understanding of where doors and walls go. Overarching this fact and looming large was the certainty that an increase in births in the Hospital would begin soon. What followed was the creation of an expanded labor and deliver unit that was operational by February 26, 2016 – only two and half months after programming was completed!
Protocols when Moving Quickly
When a project moves this quickly it is important to have a protocol in place that makes sure everything is accounted for to avoid mistakes and that missed items can be caught before it’s too late to work them in. Weekly meetings took on the function of both design and construction meetings. At the weekly meetings, IKM determined the highest priorities for decisions so that early construction bid package dates could be met. One of the side effects was that these meetings included so many people that it seemed like “everybody” attended. Quick decisions required input from all who would be involved in the project. Even though design and construction was moving rapidly, the Hospital and IKM knew a more successful project would result from deep staff involvement – not just from those that work in the Department – but also those that serve it. Hospital staff was included throughout. IKM’s HVAC, plumbing, and electrical engineering consultant, Lovorn Engineering was included at these meetings since most decisions had engineering implications. The inclusion of the Construction Manager, MBM Contracting and their major subcontractors, Keystone Electric, and Ruthrauff Sauer Mechanical, allowed better decisions regarding cost and schedule.
“Our previous experience working with the Hospital and IKM gave all parties the confidence that we could get this job done,” said Danny Brown, President of MBM contracting. “With a very aggressive schedule and a tight site, we knew it would be a challenge. The renovations occurred over two phases, required double shifts, and weekend work. But we got it done.”
A Collaborative Team Approach
They provided the construction team with a builder’s understanding of the design decisions, which made them well–integrated team members. Ongoing discussions between the design team and the construction team also helped make sure the materials specified would be available in time. A candid and transparent flow of information took place between all entities, and when necessary, smaller ad-hoc meetings (often on site) occurred in between the weekly meetings. Hospital project management played a key role monitoring schedule, cost, and making sure that IT support, security, furniture, and equipment entities were coordinated and integrated into the process.
Staying within budget was everyone’s responsibility, but Hospital project management took the lead on this issue and monitored decisions and costs on an ongoing basis. Accordingly, the budget had a contingency allowance for unforeseen circumstances, particularly important in a renovation project. Since this was a fast track project, a design contingency was also included, recognizing that construction began prior to the design work being complete. The contingency allowance covered items not anticipated by the Contractor, for modifications by the design team and the Hospital after construction operations began.
No Such Thing as “Off Work Hours” for Labor and Delivery
With the exacting knowledge that there is no such thing as off-hours work in a labor and delivery department, the design team knew that a project phasing timeline was critical to the continuing operation of the existing department at all times. IKM, MBM, and Forbes Hospital worked together to create a set of phasing plans. These plans addressed expansion and continuous operation of the infant abduction system and the staffing of added security personnel at key times. Medical gas, electrical, and plumbing shut–downs were coordinated so as not to adversely impact Hospital functions. Infection Control Risk Assessment (ICRA) measures, and access at all times by clinicians, expectant mothers, family members – as well as, those from other departments that serve Labor and Delivery – were carefully coordinated.
In a proactive move that would enable work to proceed with the proper permits, meetings with the State and local municipality for preliminary review, demolition approval, and final drawing approvals were scheduled prior to floor plan approval so that the work could proceed with the proper permits.
Approval of preliminary review and demolition was granted by the State November 18, 2015. The first bid packages were issued November 19, 2015. Lighting (the longest lead item) was reviewed and approved December 2, 2015. Work in the vacated stepdown unit began December 4, 2015. Pennsylvania Department of Health Floor Plan Approval was received December 18, 2015. Double shift work and overtime became
part of the project. The project was completed February 26, 2016 and even those involved on a daily basis were surprised at how quickly the project could be completed and with such superior results.
The execution and completion of this project, in a way that completely met the Hospital’s needs, is a tribute to the cooperation, foresight, and tenacity of the entire project team.