Master Planning

Master planning and the big picture

Simon Bruce, RIBA, Frank Zilm, D.Arch, FAIA
trategic decisions involve the allocation of scarce resources – people, equipment, and capital. These decisions are not easily reversed and typically have long term effects on an organization. In contrast to strategic decisions, tactical decisions are short term choices related to implementation of the larger strategic vision.
Buildings are one piece of a complex set of decisions that will shape an organization. Capital decisions require balancing current needs with assumptions about the future and positioning an organization to have the right configuration of space to assure appropriate, efficient, and functional execution of its defined healthcare mission. As will be outlined in this section, the life expectancy, or obsolescence, of site and building components range from a decade (equipment, interior layouts) to potentially a century (site utilization, building structures). Forecasting the specific requirements of healthcare needs and the competitive environment for any healthcare entity is a daunting task.
Although architects have the technical and design skills to lead this process, they frequently lack experience with some of the tools for assisting in effective decision making. There is also a fear that our advice may not be objective, since we would potentially benefit from larger, more expensive, projects. To overcome these barriers our profession must demonstrate the ability to communicate effectively with leaders regarding their goals. The dominant personality profile of architects is biased to making decisions on our judgment and insight. This is the way we design. Healthcare leaders are more comfortable working with data and facts. Our planning approaches must be sensitive to this decision framework.
A second bias that we need to be prepared to address is an aversion to risk. This is a basic characteristic of human behavior. We say we are risk-takers, but studies have confirmed that when faced with real choices we pull back from risky situations. This can result in a focus on fixing immediate problems rather than assessing options that may have high potential benefits, but also high potential risk.
There are three components of planning tied to space and design:

  • Estimating the scale of space needs and the fit between existing resources and projected needs[1].
  • Land use concepts that integrate access, functionality with potential long term regeneration and growth of facilities.
  • Building concepts that provide affordable strategies for adaptation and change resulting from new medical needs, organizational models, and technologies.
As discussed in the chapter on our healthcare system, there are many forces shaping the healthcare. These include:

  • Demographics of our population, particularly the aging of the “baby boomer” generation.
  • Incentives shift patient care to ambulatory, home care, and preventative care models.
  • Tight capital budgets, resulting in demands for space efficiency and reuse of existing facilities.
  • New technologies, particularly in imaging and interventional procedures.
  • Market strategies emphasizing branding, imaging, and supporting patient satisfaction.
Master Plan Process

Typical steps in the master planning process are illustrated in this diagram. Depending upon the size of the organization, completion of these tasks can take from 3 to 12 months.
A key step in this process is the assessment of existing buildings and sites. This task includes the evaluation of current conditions and capacity of individual components and services, infrastructure, structure, parking, zoning, and other conditions.

Assessing obsolescence is one major task in this phase of master planning. Obsolescence factors can be grouped into three major categories:
  • Technical – the deterioration of limit capacity of major infrastructure – HCAV, electrical, structural.
  • Functional – the mismatch between current functional needs (ambulatory surgery, interventional cath, etc.) and the facility design.
  • Cultural – the expectations of the patients, family, and community. Provision of single patient rooms is an example of a care model that is expected by patients.
Master Planning - Health Architecture

Drives of Change

The match between the assessments of existing conditions to projected need is the heart of master planning’s value. There are a number of strategies and techniques that are used during this synthesis phase. These look at siting strategies, internal department locations, testing alternative future visions, and building for flexibility/adaptability.

Scenario Analysis

The healthcare environmental issues outlined at the beginning of this chapter, combined with uncertainty regarding actions of other providers, new healthcare technologies, and national healthcare policies make the projection of space needs beyond a five year horizon extremely difficult. A planning approach that has been adapted successfully from the military and business sectors is scenario analysis.
The core of scenario planning is the identification of all external and internal factors that could affect an organization. These factors are then grouped into plausible future stories that illustrate potentially contrasting directions. At least two and ideally three scenarios are developed. The master planning process then assesses the implication of each option. The product of this process includes development strategies that are common across all scenarios and the unique plan characteristic to each scenario. This approach increases the level of confidence in a final plan approach and its ability to respond to different futures. Basically, we’re trying not to put all our eggs in one basket.

Site Planning Strategies

Virtually all patients arrive in a personal vehicle, or emergency medical service (EMS) ambulance. Site access and vehicular circulation are key organizational elements, particularly when developing new sites. Typically we try to separate at least four types of circulation – public, staff, ambulance, and service vehicles (deliveries, trash, etc.). Site area or access restrictions may not allow the complete separation of this flow, but a minimum requirement should seek to separate support vehicle traffic.

Identifying the minimum required acreage for development is a combined assessment of the land value, zoning development restrictions; anticipated future growth and the desire to control adjacent developments around the facility. In addition to the building, parking has emerged as a major site development issue. Most hospitals anticipate 3-4 parking spaces per built inpatient bed. Outpatient facilities can anticipate a similar number of total spaces per physician. This typically adds up to either large surface area lots, or expensive garages.
Two general site and building strategies have emerged for hospital design – the low density horizontally organized hospital (spine) and the high density vertically organized hospital (hub).
Master Planning Approaches

The master plan strategy should have sufficient design detail to test the feasibility of the overall development concept. For hospitals, major design drivers are typically the nursing units, major diagnostic and treatment services, and the public, patient, staff, and supply circulation patterns.
Future development to accommodate expansion or replace obsolete facilities should be a key consideration in site planning. One strategy to address future growth is the “empty chair” concept. Analogies to this model can be seen in farming practices of rotating fields dating back to the middle ages. The basic strategy is to leave undeveloped or under developed land adjacent to the high use capital assets, allowing for major adjacent expansion.
Empty Chair 1Empty Chair 2

While this concept is intuitively appealing, it can be hard to implement. The two major barriers are the purchase, and holding, of undeveloped land. A related problem is the pressure to build small, incremental additions on the adjacent property, limiting the ability to implement major development options.
Internal expansion strategies

“Hard” vs “Soft” Space
Hard vs Soft SpaceA strategy that attempt to accommodate growth and change through internal building space allocation is frequently referred to as adjacent positioning of “hard” and “soft” spaces. Hard spaces are defined as high cost, frequently with expensive technology and HVAC requirements. Surgery, imaging, radiation therapy are examples of hard spaces. Soft spaces are low density and low cost areas that can be moved to other locations without major disruption. Administrative space, physical therapy, ambulatory clinics are examples of these spaces.
By locating soft space adjacent to hard space services a hospital can buy a strategy for internal growth of departments.

Modularand Universal Spaces
Another strategy for incorporating flexibility into design seeks to size components for future reassignment to other functions and to build in a common grid that makes adaptation easier.
A modular approach typically attempts to identify a basic building block room size. This room size may be determined by the overall structural bay, or by the smallest patient care component. An example would be designing an outpatient area based on a typical exam room of 120 nsf. Other areas, such as offices, supply rooms, and other space would be built on multiples of this room size – 120, 180, 240, etc. This facilitates the remodeling of areas to accommodate new functions.
Another strategy to achieve flexibility is to develop “universal” treatment spaces. This has been executed successfully in imaging and surgery services. The goal is to define rooms large enough to accommodate changes in procedures and equipment. When these areas are placed together, with appropriately designed support areas the space is frequently referred to as a “zone of flexibility.”
Universal Treatment Rooms
Both of these strategies can achieve limited long term adaptability, but come at a cost of building some areas larger than current needs. The larger universal rooms may also affect the circulation and functionality of the space.

Maximum Vertical and Remodeling Flexibility – Building System Concept

As outlined in the history section, during the late 1960s and 70s there was a great interest in looking for a “systems” approach to design. This was, in part, a reaction to the incredible success demonstrated by the space program and in the application of systems thinking to operations management.
The VA building systems concepts, developed by leaders including George Agron, Tib Tusler, Ezra Erenkratz sought to define a overall building system strategy that would allow for maximum long term flexability. Modular building blocks, long span structures, and interstitiatal floors are among the elements integrated into a single strategy.
VA Building SystemVA Planning Module
A key assumption of this approach is that potentially higher initialconstructioncosts would be offset by the ability to efficiently execute remodeling. If you could calculate the “life cycle” costs of this approach it would prove effective. A second benefit of the interstitial concept is that it provides an effective strategy to accommodate vertical constuction above occupied areas of a hospital.
Unfortunately there have been few studies to confirm the potential life cycle cost saving. There has also been debate over the initial first dollar costs. The 7-8 foot height of an interstitial floor adds cubic square footage to the building, and additional costs of flooring and access walkways. Advocates for the interstitial concept argue that careful vertical zoning of the interstial space reduces conflict and allows construction trades to access areas simultaneously.
A study completed by Health and Welfare of Canada in 1979 concluded that the interstitial strategy had value in diagnostic and treatment areas, but limited value above nursing unit floors. No comparative studies of VA hospitals with and without interstital have been completed. Pressure to maximize first dollar costs into immediately functional space has influence decisions regarding this long term strategy.

Putting it All Together
There are a broad range of planning tools and approaches that are available for an individual project. The art of the planning process is to assemble the right team and use the appropriate tools for the specfic project.

Master Planning - Health Architecture

When executed properly a sound master plan establishes a framework for logical growth and adaptation for decades into the future.

[1] Method for projecting space needs will be discussed in a separate section of this Guide.

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