Design &amp; Construction Process Toolkit

See Evidence Based Design tab for EBD activities during this phase

Conduct Operational Planning (C)

Define the services to be offered and how care will be delivered. Both may be different from the existing conditions.

Determine Staffing Needs (C)

Evaluation of the number and type of staff based on services you expect to provide and expected number of patients.

Conduct Allocation Planning/Preliminary Space Assessment (C, D)

A systematic accounting of each program and/or department that results in a reasonably good estimate of how much space (usable, net square feet) will be required for the envisioned operations.

Finalize Strategic Planning (C)

The strategic plan is a definition of your organization’s long-term vision and the short-term objectives. It helps align facility design with the organizational mission to best achieve care delivery and business goals.

Develop Community Awareness/Engagement (C)

The proposed project should be supported by the community. Foster goodwill for the project by creating an understanding of the project scope, services, and potential impact on traffic. Consider how the community and patient perspective will be used to develop the project.

Develop the Business Plan (C)

A roadmap that outlines supply, demand, costs, and revenue stream. It also provides insights into how different decisions will affect your return on investment, cash flow, debt load and work processes.

Plan for the Project Mission/Vision (C)

The project mission and vision establishes project goals and objectives - guiding principles that should be used throughout the design and construction to guide decision making.

Create Project Organizational Leadership (C)

The team is established to implement the project – with a unified management structure, authority to manage the project and accountability for results.

Development of Project Budget (C)

Sets the stage to obtain financing and includes both sources of funds and how funds will be used, along with hard costs (construction), soft costs (professional fees, permitting) and contingencies (unknowns).

Explore various financing options (C)

There are multiple financing options, such as conventional loans, community development institutions, federal funding, foundations, or bonds, supplemented by clinic funds reserved for the project, and/or a capital fundraising campaign.

Consider Sites (C)

Aside from cost, site selection considerations can include: accessibility to nearby services, topography, size, configuration, water, sewage, and drainage issues. Sites can be purchased or leased.

Conduct Peer Site Visits (C)

Visiting others allows you to see what is being done elsewhere in order to benchmark and begin a “wish list” of design features to consider.

Develop a Preliminary Project Schedule (C)

High level goals for major milestones and project completion.

Hire a Project Manager and Architect (C)

Select a project manager with relevant development experience and an architect with relevant healthcare experience. Orient yourself to the process and conduct a series of informal discussions with the staff to solicit their ideas, desires, and expectations about a potential project.

Create Project Organizational Leadership (C)

The team is established to implement the project – with a unified management structure, authority to manage the project and accountability for results.

Assess Project Needs and Viability: Includes Operations and Finances (C)

This includes assessing the facility’s current and anticipated space needs based on programs/services and anticipated volumes and determination of whether to renovate or build new. Sometimes the cost of renovation can exceed the cost of a new building, and an analysis needs to be completed to determine the best option.

Initial Assessment Phase: Operations and Finance

Assessing the facility’s current and anticipated space needs based on programs/services and anticipated volumes. Determine whether to renovate or build new - sometimes the cost of renovation can exceed the cost of a new building. An analysis needs to be completed to determine the best option.

Lead by: Provider

Evidence-Based Design Activities

EBD Step 1: Define EBD Goals & Objectives

At the core of an evidence-based design process is the link between design and desired outcomes. This can be established early in the process through visioning - defining broad goals and objectives for the project that support the organization’s mission and vision. Continually referencing these goals throughout the process helps the team evaluate various design strategies and keep the project on track. Consider the following steps and related questions.

Use the arrow to expand or collapse this section

Assemble interdisciplinary design team (P)

In addition to the architect, the executive director, the staff, and the board of directors, each have a unique role and perspective to share during the development process. Your team may include an executive steering committee, as well as subgroups. In an evidence-based design process, there is a diverse group of stakeholders who bring varying perspectives to help define the goals, objectives, and solutions. Are there specialty consultants you might need, such as an expert in project development, clinical processes or technology? Determine how patient and staff input will be gathered throughput the process and how they will be represented at an executive level. Have roles and related scope of responsibility been defined for each team member?

In a clinic setting, it is a good idea to poll your Board, staff, and other volunteers to find out what expertise they may be able to contribute to the project, whether developing a business plan or understanding construction. You may also find experts in your community that are willing to help, but it is important to define expectations, especially when work is being offered pro bono.

Identify issues and/or problems (P)

Consider if there are key areas or outcomes that would be of interest to your community and organization. What problems or issues are you trying to solve? What is it that you hope to achieve to support your strategic plan, business case, and/or care model? In a clinic setting, community issues might include access to care or compliance rates for care regimens. Organizational problems might include staff efficiency.

Define Outcomes (P)

Defining the intended outcomes will provide clarity for everyone involved throughout the duration of project. Outcomes may be closely tied to staff, patient and/or family and will most likely involve operational, administrative and cultural changes. What are the anticipate improvements or changes to be achieved through a new or renovated building?

In a clinic setting, outcomes might include patient & clinical outcomes, such as improving access to care by providing easy access to public transportation, improving compliance with care regimens through family engagement in care. Staff outcomes might include improved efficiency offered by a medical home model and its related layout (that may improve patient compliance, as well). It may also include operational outcomes, such as reduced long-term operating costs. Long term costs need to be carefully considered relative to “first” (capital) costs in development of the business case.

EBD Step 2: Find Sources for Relevant Evidence

As the team begins to develop design guidelines, the search for relevant evidence begins. Knowing what strategies are supported by evidence will depend upon a review of the literature. A resulting set of project priorities is defined in conjunction with the literature review findings.

Inform design challenge and formulate research questions (P, R)

In addition to defining the issues and problems, consider what additional questions need to be raised and the evidence that might be used to inform decisions. Learn about what others have done through benchmarking visits or interviews to establish some early ideas to guide the project.

In a clinic setting, this may include better understanding models of care, their delivery, and how this affects the building layout and space requirements. Your questions may focus on how effectively you are able to deliver care in the new model by measuring throughput times, compliance, and satisfaction. You may want to engage a researcher to help identify research questions, but you may be able to identify certain questions and related metrics on your own through information you already gather.

Identify types of evidence (P, R)

Initially, it is important to identify all types of evidence, such as published papers, case studies, peer interviews, site visits, and structured benchmarking. The type of evidence may be tied to the type of information your team is trying to learn – newer information may only be found while conducting a site visit, rather than in a published format.

There are very few peer-reviewed published papers that will identify conditions specific to clinic settings, however, information can often be extrapolated from other environments, whether acute care or ambulatory care. It is important to get help understanding how less rigorous sources can still be applied to a clinic setting. This may be through a researcher or someone well-versed in the EBD process who can establish some guidelines for how you might best use the information collected.

FAQs

Print FAQs

What are the deliverables I should expect during organizational readiness?

Key deliverables during this phase include: project concept and direction, a needs assessment, a business plan, and a preliminary space assessment

How do I determine how much space I might need?

The space assessment is usually completed by an architect with input from the Provider on how spaces are used for both tasks and overall workflow. The result is a comprehensive listing of every room and/or space in the facility, its estimated square footage, and additional space required for circulation, mechanical, and utilities that is balanced with codes, guidelines and other requirements. You should consider your future operating vision, as well as several scenarios of what might change in 10 years to understand how your vision differs from the present and what to consider for flexibility.

What should be defined for each person’s role and responsibility?

It is important to define expectations for the participants, including the duration of the project, decision-making authority and processes, and project deliverable responsibilities. Understanding expectations of those participating is also important to encourage an open two-way dialogue.

What is included in the business plan?

It typically includes an executive summary, clinic history and operations, management and governance, market analysis and strategy, the facilities project, the financial operations, including historical data, capital needs, and projected performance.

Resources

Print Resources

My Safety-Net Clinic: Cost-Benefit Tool

Created by Western Michigan University. My Safety-Net Clinic (MySNC) is a tool to help clinics and designers understand the costs associated with various aspects of renovating, or designing a clinic. Use the tool to calcuate costs for the following areas:

Waiting Areas
Patient Care Areas
Greeen Design
Exterior Lighting

Phases and activities related to this tool include:

Organizational Readiness

Develop the business plan
Develop the project budget
Explore various financing options

Pre-Design

Determine financial feasability
Plan and program
Refine project budget/schedule

Breaking Ground: A comprehensive planning guide for health center projects

Created by NCB Capital Impact. Phases and activities related to this resource include:

Organizational Readiness

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Develop community awareness/engagement
Develop the business plan (Sect VII)
Development of project budget
Explore various financing options
Develop a preliminary project schedule
Hire a project manager and architect (Sect IV)

Pre-Design

Determine financial feasability
Conduct a market needs analysis and assessment
Select/survey sites and evaluate space availability (Sect IV.b)
Select an attorney, architect/interior designer, contractor and construction manager
Establish the remaining project team
Property aquisition/site control
Refine project budget/schedule (Sect VIII)

Design

Continue conceptual diagramming
Design development
Permit process
Zoning/use processing
Furniture, fixtures, equipment (FFE) and technology planning
Purchasing plan
Construction documents
Value engineering (p. 33)
Early permit - third party approvals (p. 40-41)
Bid and award - this may be phased, based on contract type

Construction

Conduct construction inspection and surveillance (p. 43-49)
Create the punch list (p. 55)

California's Safety-net Clinics: A Primer

Created by the California HealthCare Foundation. Phases and activities related to this resource inlcude:

Organizational Readiness

Development of project budget
Explore various financing options

Occupancy

Liscensing

EDAC Study Guide 3

Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process.

Guide Three pulls together the evidence-based design (EBD) process to walk you through the key steps of the design process in detail from pre-design, design, construction and occupancy. Practical examples demonstrate key areas and show how EBD is practically applied.

Phases and activities related to this resource include:

Organizational Readiness

Pre-Design

Evaluate work flow
Start conceptual diagramming

Design

Continue conceptual diagramming
Design development
Bid and award-this may be phased based on contract type

Construction

Substantial completion
Final completion

Occupancy

Community development financial institutions (CDFI), Nonprofit Finance Fund® (NFF)

Created by the Nonprofit Finance Fund who makes loans to nonprofits and pushes for fundamental improvement in how money is given and used in the sector. Phases and activities associated with this resource include:

Organizational Readiness

Develop the business plan
Development of project budget
Explore various financing options

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

LEAN: Overview of a Customizable Lean Health Care Transformation Program

Created by NC State University. Phases and activities related to this resource include:

Organizational Readiness

Assess project needs and viability: includes operations and finances
Conduct operational planning
Plan for the project mission/vision
Create project organizational leadership

Pre-Design

Evaluate work flow

Launching a Capital Facility Project: A guide for healthcare leaders

Authored by John E. Kemper. Phase related to this resource is Organziational Readiness.

Business Plan Template

Created by Anita Addison of La Clinica de la Raza for the Promising Practices Seminar in 2011. The phases and activities that are applicable to this resource include:

Organizational Readiness

Develop a business plan

USDA Captial Assistance Funding: A Rural Health Resource Guide

Created by the USDA. Phases and activities related to this resource include:

Organizational Readiness

Develop project budget
Exlpore various financing options

Pre-Design

Start a capital campaign feasability study
Develop a capital process/fiscal plan

VA Building and Interior Design Guidelines (multiple resources)

Created by the Veterans Administration. The attached files are guidlines for working with the VA in primary care settings. Phases and activities that relate to these resources include:

Organizational Readiness

Conduct allocation planning/preliminary space assessment
Site considerations (note narrative)

Pre-Design

Conduct a market needs analysis and assessment
Create space function/flow analysis
Plan and program

Design

Continue conceptual diagramming
Design development
Furniture fixtures, equipment (FFE) and technology planning

Who Moved the Finish Line? Redefining Readiness in a World Obsessed with Go-Live

Created by Deloitte. Phases and activities included in this phase include:

Organizational Readiness

Conduct operational planning
Determine staffing needs
Develop a business plan
Plan for the project mission/vision

Construction

Internal readiness

Facility Expansion & Renovation Planning for Capital Projects & Campaigns

Created by Gates Family Foundation. Phases and Activities applicable to this resource include:

Organizational Readiness

Conduct operational planning
Develop community awareness/engagement
Develop a business plan
Development of project budget
Explore various funding options

Pre-Design

Determine financial feasability
Start a capital campaign feasibility study
Develop a capital process/fiscal planning
Continue community engagement and collaboration
Refine project budget and schedule

Design

Design development

Report from the Field: Insights by Community Clinics on Information Technology Adoption

Created by the the Comunnity Clinics Initiative. Phases and Activities applicable to this resource include:

Organizational Readiness

Create a business plan

Pre-Design

Evaluate work flow
Refine project budget and scope

Design

Design development

Creating a Business Plan for a Commnity Health Center Capital Project: A "How-to" Manual

Created by Capital Link. Phases and Activities applicable to this resource include:

Organizational Readiness

Develop a business plan

A free resource from Capital Link and Primary Care Development Corporation on developing a health center. Phases and Activities applicable to this resource include:

Organizational Readines

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Create project organizational leadership
Development of project budget
Explore various financing options
Consider sites (see chapter 5)
Develop a preliminary project schedule (see chapter 2, and Appendix B)
Hire a project manager and architect

Pre-Design

Determine financial feasability
Select/survey sites and evaluate space availability (see chapter 5)
Select an attorney, architect/interior designer, contractor and construction manager (see chapter 3-4, 6 and Appendix D)
Establish the remaining project team (see chapter 4, Appedix D and E)
Property aquisition/site control
Plan and program
Refine project budget/schedule
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Construction documents
Bid and award - this may be phased based on project type (see chapter 7)

Construction

Notice of completion
Final completion
Transition planning

Resources for Capital Development: Community Clinics Initiative

The Community Clinics Initiative and Capital Incubator developed a list of tools and resources for capital development projects. Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Plan for the project mission/vision
Development of a project budget
Explore various funding options

Pre-Design

Determine financial feasability
Start a capital campaign feasability study
Develop a campital process/fiscal planning

Capital Campaign Readiness Quiz

Many ingredients combine to make a successful capital campaign. To help you determine if your organization is well positioned to move into a formal campaign planning process, we’ve developed the following Campaign Readiness Quiz. Answer yes or no to these questions then check your score to see how well you are positioned and what your next step may be. Created by Pathway Associates

Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Development of project budget
Explore various financing options

Pre-Design

Determine financial feasability
Develop a capital process/fiscal planning
Continue community engagement and collaboration

Self-Assessment of Organizational Readiness to Develop

New York State Division of Housing and Community Renewal (DHCR)/Franke Consulting Group developed a checklist for Organizational Readiness. While the checklist is for housing, most of the questions can be adjusted for clinics.

Phases and Activities applicable to this resource include:

Organizational Readiness

Conduct operational planning
Determine staffing needs
Create project organizational leadership

A Toolkit for Redesign in Healthcare: Case Study

Prepared For the Agency for Healthcare Research and Quality (AHRQ), 2005. The broader and deeper the scope of the redesign effort of a hospital, the more likely redesign produces system-wide transformation. For the purposes of this project, “redesign” and “system transformation” will both be used to describe the desired process outcomes.This project was supported by the Agency for Healthcare Research and Quality.

Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Develop community awareness and engagement
Create project organizational leadership

Pre-Design

Evaluate work flow
Start conceptual diagramming

Clinic Examples

Print Clinic Examples

Thundermist Health Center

Unique feature: New medical model of admission/reception office

Through involvement with the Institute for Healthcare Improvement's Re-designing the...

Grace Hill Neighborhood Health Center-Water Tower

Grace Hill Neighborhood Health Centers is a FQHC, Federally Qualified Health Center, whose mission is to provide a medical home to the uninsured and under insured in St. Louis City. The design...

La Clinica de la Raza at Fruitvale Transit Village

Unique feature: The Clinica de la Raza Community Health Center is a component of a transit-based development village that provides physical renewal and economic...

Pre-Design

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What is Pre-Design?

Pre-design is the phase of analysis that occurs after some form of funding is available and before design begins. During the pre-design phase, studies are done to analyze space requirement issues, the constraints and opportunities of the proposed site, and the cost versus the budget.

The amount of funding available in the pre-design phase varies and is a critical factor in determining which studies take precedence. Funds may be available to develop a detailed project program or only to investigate certain technical issues in order to determine scope, budget, or project schedule.

Pre-Design Activities

Activities occurring during pre-design that are led by the healthcare organization include: launching a capital planning campaign, determining financial feasibility (such as debt, equity, insurance/contracts), developing and establishing project team, ensuring community engagement and collaboration is integrated in the planning process, working with neighborhood leaders, obtaining property acquisition and site control, finding out city/county/state requirements, and refining the project budget.

Continuing from Organizational Readiness, Lean processes and sustainability are further developed in pre-design.

Evidence-Based Design

During pre-design, you will continue with Step Two:, find sources for relevant evidence; and then move to Step Three: critically interpreting the evidence. See the Evidence-Based Design Tab for more detail about EBD activities during this phase.

Sustainability

Define whether your project will achieve LEED status (and at what level) or just follow USGBC or Green Guide for Healthcare (GGHC) recommendations. Review the LEED checklist for site selection and other categories. Determine whether you need an expert in this area to assist your team. An architect or designer with LEED accreditation or experience is a good resource.

Lean Processes

Lean Processes: Provided your organization is culturally ready to undertake a Lean process initiative, what is the desired future state? Value Stream Mapping looks at the process from the customer's point of view. It shows all steps in a given process and enables the team to identify waste in the process.

All types of processes can be mapped, from admitting, discharge, billing, medication requirements, patient procedures, etc. The “map” starts with the first step of the process and continues through to the last step of the process. This is the value stream from which you can simplify work processes, eliminating inefficiencies, improving quality and improving patient care. Consider whether you need an expert in this area to assist your team.

Design Activities

Select an Attorney, Architect/Interior Designer and contractor and construction manager (C)

See Evidence Based Design tab for EBD activities during this phase

Determine Financial Feasibility (C)

Study the cash flow, profitability potential, and overall desirability of the project. Determine building process to be used (such as design-build, design-bid-build).

Start a Capital Campaign Feasibility Study (C)

Identifying funding sources (people, foundations, etc.) and scale of potential contributions. Create informal financial funding commitments.

Conduct a Market Needs Analysis & Assessment (C, D)

Establish the organization's current or potential markets, forecast of directions, and decision on how to expand the volume, services, etc.

Develop a Capital Process/Fiscal Planning (C) (D)

Your project will span more than one fiscal year, so it is essential to consider the cash flow and how funds will be committed from year to year. A design professional or construction manager should help establish reasonable timeframes.

Establish the Remaining Project Team (C)(D)

Consider program planners, financial experts, real estate advisors and design specialists as needed (wayfinding, for example), as well as staff, patients and families.

Execute contracts with key team members (architect/interior designer for planning activities, and contractor for preliminary cost estimates) and an attorney.

Continue Community Engagement and Collaboration(C)(D)

Collect views and opinions of those affected by the project

Property Acquisition/Site Control (C)

If available and financially feasible, purchase and prepare the site prior to construction. This may also happen in later phases.

Define City/County/State Requirements(C)

Determine if analyses and preliminary concepts meet city/county/state requirements

Evaluate Work Flow (C)

Consider the patient and staff experience and determine why a process is done in a certain way and whether it can be improved.

Create Space Function/ Flow Analysis (C)(D)

Determine flow for patients, staff, and ancillary services through mapping of movement of people, materials, and information.

Benchmark (C)(D)

Comparing an organization's performance against the "best in the business" to gauge room for improvement and progress toward excellence – aids in “wish list” development.

Refine Project Budget/Schedule (C)

Identify all the costs you will have to incur to build and start operating your center – an informed guesstimate in the early phases. Include adequate contingencies in both the budget and schedule and evaluate the Return on Investment (ROI) over time. Refine the high-level project schedule to incorporate all major activities during each phase of the project.

Start Conceptual Diagramming (C,D)

The design team will develop large block (or “bubble”) drawings showing the basic concept of a floor plan, major service and/or activity areas, adjacencies and space flow. It should consider how the facility is envisioned to operate through a functional narrative.

Review project mission vision

Modify the mission and vision if there have been any developments from the Organizational Readiness phase

Plan & Program (D)

Conduct preliminary analysis for space requirements. Ensure the design team spends time at the site to observe processes, discuss clinical issues, and understand the values of the organization.

Select/Survey Sites and Evaluate Space Availability(D)

Identify real needs versus “wants” or non-essentials.” Consider staff, volunteer, constituent, and visitor needs and usage.

Evidence-Based Design Activities

EBD Step 3: Critically Interpret Evidence

Due to the lack of research in clinic-specific environments, it is important to understand how relevant and credible the information is before embarking on any major decisions. Critically interpreting the evidence is achieved in several ways: Date, location, scope, and source. Is the author a recognized expert? Are there other studies on this topic? Is the source reputable? Is it peer reviewed?

Determine relevance of evidence collected (P,D)

Is the information credible (a defined scope from a reliable source), actionable (suited to your organization), and generalizable (are outcomes transferable to a clinic setting)?.

Hierarchy of credible evidence (P,D)

Consider the quality of the research design and measurement tools. The range of hierarchy spans from very subjective and context specific, such as opinions, through Post-Occupancy Evaluations, Case Studies, Surveys, and through to more objective types of studies, such as Controlled Observational Studies, Quasi-Experimental Studies, and Randomized Control Trials. Systematic Reviews can be a good resource to understand the breadth of studies within a topic area, as well as an overview of the consistency of findings.

Reliability and validity (P)

When considering evidence, reliability and validity are key considerations. Validity is the extent to which a measurement tool measure what it should, and reliability is the degree to which the tool will yield similar results at different times or with different people. For example on a more subjective scale, opinions may not be valid or reliable, but a survey using a validated survey instrument may provide more meaningful results.

Identify any conflicting findings and confounding variables (P)

Consider multiple studies (when available) with differing results or other changes (multiple simultaneous interventions) that could affect study outcomes. Before making decisions, ask the team to whether there were conflicting findings or confounding variables.

Refine project budget/ revisit the business case (P,D)

Based upon the available research, there may be some design ideas you want to incorporate into the facility. This may affect the capital budget, but should be evaluated against the long-term benefits and operating costs. Establishing a life-cycle analysis of ROI should support your business case.

EBD Step 2: Find Sources for Relevant Evidence

Inform design challenge and formulate research questions (P, R)

Identify types of evidence (P, R)

FAQs

Print FAQs

Why do I need an attorney for a design project?

An attorney is engaged after preliminary planning work is done but before you hire any members of the project team. An attorney should ensure that contracts with team players reflect the business terms you negotiate and protects you. They also negotiate and/or review legal documents for site acquisition and funding, and may represent you in zoning matters. (NCB Planning Guide)

Why do I need to think about work flow so early?

It is critical that you consider new workflow patterns when starting design, as most organizations adapt their process based on the restrictions of space or resource availability. Consider a 10-25-year horizon and evaluate different scenarios to determine what changes in volume, services, or techno logy might do to flow. This can add 10-12 weeks to what people might assume to be 2 sessions; but is essential to understand why it is done this way now and whether it can be improved from both a staff and patient perspective.

What are the key deliverables I should expect during pre-design?

Key deliverables include reports to outline the financial and capital campaign feasibility, a market needs assessment, and a functional program with preliminary diagramming to illustrate required adjacencies and workflow requirements.

Resources

Print Resources

My Safety-Net Clinic: Cost-Benefit Tool

Waiting Areas
Patient Care Areas
Greeen Design
Exterior Lighting

Phases and activities related to this tool include:

Organizational Readiness

Develop the business plan
Develop the project budget
Explore various financing options

Pre-Design

Determine financial feasability
Plan and program
Refine project budget/schedule

Captial Project Solutions: Integrated Project Delivery--Team Selection

Created by KLMK Group. Throughout 2010, Capital Project Solutions ran a series of articles dedicated to Integrated Project Delivery (IPD) exploring all issues related to IPD, from project identification to team selection to contract and incentive development. With three (3) IPD projects currently underway this report shares case studies and lessons learned throughout the series. The phases and activities related to this resource include:

Pre-Design

Establish the remaining project team

Breaking Ground: A comprehensive planning guide for health center projects

Created by NCB Capital Impact. Phases and activities related to this resource include:

Organizational Readiness

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Develop community awareness/engagement
Develop the business plan (Sect VII)
Development of project budget
Explore various financing options
Develop a preliminary project schedule
Hire a project manager and architect (Sect IV)

Pre-Design

Determine financial feasability
Conduct a market needs analysis and assessment
Select/survey sites and evaluate space availability (Sect IV.b)
Select an attorney, architect/interior designer, contractor and construction manager
Establish the remaining project team
Property aquisition/site control
Refine project budget/schedule (Sect VIII)

Design

Continue conceptual diagramming
Design development
Permit process
Zoning/use processing
Furniture, fixtures, equipment (FFE) and technology planning
Purchasing plan
Construction documents
Value engineering (p. 33)
Early permit - third party approvals (p. 40-41)
Bid and award - this may be phased, based on contract type

Construction

Conduct construction inspection and surveillance (p. 43-49)
Create the punch list (p. 55)

CHD White Paper: New Models of Care Delivery

Written by The Center for Health Design for the California HealthCare Foundation. The design of the physical environment plays an important role in improving health care quality, work efficiency, and cost-effectiveness. Safety-net clinic design can have a substantial impact on the effectiveness of innovative care delivery models, but guidelines are limited. To contribute to a better understanding of the topic, this white paper seeks to identify key characteristics of the physical environment design for new care delivery models and to provide preliminary design recommendations.

Phases and activities related to this resource include:

Pre-Design

Select/survey site and evaluate space availability

Design

Continue conceptual diagramming
Schematic design
Design development
Furniture, fixtures, equipment (FFE) and technology planning

CHD White Paper: Culture

Written by The Center for Health Design for the California HealthCare Foundation. Cultural issues that may affect patients' healthcare interactions include models of health and disease; perception of hospitals, doctors, and other healers; hierarchical vs. egalitarian cultures; family and social relationships; and communication norms. These factors influence patients' health-seeking behavior as well as their relationships with providers and clinics.

This paper suggests several design strategies to support culturally sensitive care, including the need for patient and family engagement throughout the planning and design process. Other recommendations include locating the clinic within the community, devising a wayfinding system to enable easy navigation, and designing the waiting areas and exam rooms to support the presence and involvement of families.

Phases and activities related to this resource include:

Pre-Design

Space function/flow analysis

Design

Continue conceptual diagramming
Design development
Furniture, fixtures, equipment (FFE) and technology planning

An owner’s guide to construction management.

Created by Construction Management Association of America (CMAA). Phases and activities related to this resource include:

Pre-Design

Select an attorney, architect/interior designer, contractor and construction manager

Design

Construction

Establish project controls
Substantial completion
Notice of completion
Final completion

EDAC Study Guide 3

Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process.

Guide for Sustainable Projects, including Agreement Amendments and Supplementary Conditions

Phases and activities related to this resource include:

Organizational Readiness

Pre-Design

Evaluate work flow
Start conceptual diagramming

Design

Continue conceptual diagramming
Design development
Bid and award-this may be phased based on contract type

Construction

Substantial completion
Final completion

Occupancy

IHI Information Gathering Tools

Created by the Institute for Healthcare Improvement. The phases and activites related to this resource include:

Pre-Design

Create space function/flow analysis
Start conceptual diagramming

IHI Improvement Report: Redesigning Ambulatory Care: Delivering the Promise

Created by IHI, Borgess Health: Borgess Ambulatory Care, Kalamazoo, Michigan, USA. Activities and phases related to this resource include:

Pre-Design

Create space function/flow analysis
Start conceptual diagramming

Created by the AIA. Phases and activities related to this resource include:

Pre-Design

Select an attorney, architect/interior designer, contractor and construction manager

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

LEAN: Overview of a Customizable Lean Health Care Transformation Program

Created by NC State University. Phases and activities related to this resource include:

Organizational Readiness

Assess project needs and viability: includes operations and finances
Conduct operational planning
Plan for the project mission/vision
Create project organizational leadership

Pre-Design

Evaluate work flow

USDA Captial Assistance Funding: A Rural Health Resource Guide

Created by the USDA. Phases and activities related to this resource include:

Organizational Readiness

Develop project budget
Exlpore various financing options

Pre-Design

Start a capital campaign feasability study
Develop a capital process/fiscal plan

VA Building and Interior Design Guidelines (multiple resources)

Created by the Veterans Administration. The attached files are guidlines for working with the VA in primary care settings. Phases and activities that relate to these resources include:

Organizational Readiness

Conduct allocation planning/preliminary space assessment
Site considerations (note narrative)

Pre-Design

Conduct a market needs analysis and assessment
Create space function/flow analysis
Plan and program

Design

Continue conceptual diagramming
Design development
Furniture fixtures, equipment (FFE) and technology planning

Labs for the 21st Century: Bid and Award

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process with a focus on sustainability.

Labs for the 21st Century: PreDesign

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process and is mostly related to sustainability. This specific resource and link is for Pre-Design. Relevant Pre-Design activities include:

Pre-Design

Establish the remaining project team
Define city/county/state requirements
Benchmark

Facility Expansion & Renovation Planning for Capital Projects & Campaigns

Created by Gates Family Foundation. Phases and Activities applicable to this resource include:

Organizational Readiness

Conduct operational planning
Develop community awareness/engagement
Develop a business plan
Development of project budget
Explore various funding options

Pre-Design

Determine financial feasability
Start a capital campaign feasibility study
Develop a capital process/fiscal planning
Continue community engagement and collaboration
Refine project budget and schedule

Design

Design development

Report from the Field: Insights by Community Clinics on Information Technology Adoption

Created by the the Comunnity Clinics Initiative. Phases and Activities applicable to this resource include:

Organizational Readiness

Create a business plan

Pre-Design

Evaluate work flow
Refine project budget and scope

Design

Design development

Checklist: Sustainable Community Health Center Renovations

Created by Capital Link.

Phases and Activities applicable to this resource include:

Pre-Design

Select/survey sites and evaluate space availability

Design

Design development

Self-Assessment of Organizational Readiness to Develop

Created by New York State Division of Housing and Community Renewal (DHCR)/Franke Consulting Group.

CHD White Paper: Flexibility

Created by The Center for Health Design for the California HealthCare foundation, this white paper discusses research and best practices around designing clinics spaces that are flexible and adaptable.

Phases and Activities applicable to this resource include:

Pre-Design

Evaluate work flow
Plan and program
Start conceptual diagramming

FGI Guidelines for Design and Construction of Health Care Facilities

Created by the Facility Guidelines Institute, 2010 edition. There is a read only version of the guidelines at the bottom of the linked page. Phases and Activities applicable to this resource include:

Pre-Design

Select/survey sites and evaluate space availability
Property aquisition/site control
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Permit process
Zoning/use processing
Construction documents

Construction

Notice of completion
Final completion
Commissiong phase

Occupancy

Certificate of occupancy
Licensing

Outpatient Clinic: Whole Building Design Guide

Developed by the Whole Building Design Guide a program of the National Institute of Building Sciences.

Phases and Activities applicable to this resource include:

Pre-Design

Plan and program

Design

Schematic design

A free resource from Capital Link and Primary Care Development Corporation on developing a health center. Phases and Activities applicable to this resource include:

Organizational Readines

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Create project organizational leadership
Development of project budget
Explore various financing options
Consider sites (see chapter 5)
Develop a preliminary project schedule (see chapter 2, and Appendix B)
Hire a project manager and architect

Pre-Design

Determine financial feasability
Select/survey sites and evaluate space availability (see chapter 5)
Select an attorney, architect/interior designer, contractor and construction manager (see chapter 3-4, 6 and Appendix D)
Establish the remaining project team (see chapter 4, Appedix D and E)
Property aquisition/site control
Plan and program
Refine project budget/schedule
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Construction documents
Bid and award - this may be phased based on project type (see chapter 7)

Construction

Notice of completion
Final completion
Transition planning

Resources for Capital Development: Community Clinics Initiative

The Community Clinics Initiative and Capital Incubator developed a list of tools and resources for capital development projects. Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Plan for the project mission/vision
Development of a project budget
Explore various funding options

Pre-Design

Determine financial feasability
Start a capital campaign feasability study
Develop a campital process/fiscal planning

Capital Campaign Readiness Quiz

Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Development of project budget
Explore various financing options

Pre-Design

Determine financial feasability
Develop a capital process/fiscal planning
Continue community engagement and collaboration

A Toolkit for Redesign in Healthcare: Case Study

Phases and Activities applicable to this resource include:

Organizational Readiness

Assess project needs and viability: Includes operations and finances
Develop community awareness and engagement
Create project organizational leadership

Pre-Design

Evaluate work flow
Start conceptual diagramming

Clinic Examples

Print Clinic Examples

Anchorage Native Primary Care Clinic

For the past 10 years, Southcentral Foundation has been revisiting the design process for their Anchorage Native Primary Care Clinic. In 2009, 80,000 square feet was added. Informing the design is...

Grace Hill Neighborhood Health Center-Water Tower

Grace Hill Neighborhood Health Centers is a FQHC, Federally Qualified Health Center, whose mission is to provide a medical home to the uninsured and under insured in St. Louis City. The design...

La Clinica de la Raza at Fruitvale Transit Village

Unique feature: The Clinica de la Raza Community Health Center is a component of a transit-based development village that provides physical renewal and economic...

La Maestra Community Health Clinic

Unique feature: Pursuing Gold Level LEED Certification

La Maestra Community Health Centers, located in the heart of City Heights in central San Diego,...

Merced Suites Health Center

The Golden Valley Health Centers have been serving the community for 36 years with its first clinic in Merced, California. They have 26 sites and 3 mobile clinics. On the basis of their experience...

Design

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What is the Design Phase?

The Design phase includes schematic design (SD), design development (DD), and the creation of construction documents (CDs). The phases range from high-level concepts in schematic design through refinement of details during design development, and providing all information required for bidding and building in construction documents.

Depending on how the project is implemented, these phases can overlap. For example, if your project is design-build, certain aspects of the building (such as building infrastructure) may be finalized before others (such as interior details).

During the design phase, the design intent should illustrate the relationships between project components (adjacencies, forms, size, and overall appearance). Floor plans, sections, ceiling plans, power/communication plans, finish plans, elevations, construction details and written specifications are refined for the project. Coordination with mechanical, electrical, plumbing, fire protection, and other building systems are completed during this phase.

Some question you should ask during this phase are:

What project components require outside expertise such as lighting design, landscape design, wayfinding, or acoustical design?
How can the site topography be maximized to capture the best views, building access, and landscape features?

Many design decisions of varying level of detail need to be made at this stage. Activities occurring during design that are also led by the healthcare organization include: selecting a construction manager/general contractor for estimating, if not already engaged during predesign, determining specialty consultants needed for project, initiating the permit process, and developing a purchase plan for items not included in the design and construction scope of work (often furniture and equipment).

Design Activities

Activities developed during this phase that are led by the design team include: refining the space function/flow analysis, confirming the conceptual diagramming developed during pre-design, and architectural design process (schematic design, design development, furniture fixtures, equipment, technology planning, and construction documents).

Evidence-Based Design

The evidence to support design concepts gathered during the pre-design phase can be supplemented with additional detailed evidence to answer specific issues or questions that come up during design. Review and interpret any additional evidence for its quality and applicability to your project.

As design details are developed, you can create preliminary hypotheses linking the design innovations with potential outcomes—for example, the use of a defined entrance and clear signage will improve access and navigation for patients. Define outcome metrics for the set interests prioritized by your organization and collect baseline data in the existing facility (if relevant).

The EBD steps that occur in this phase include: Step Four: create and innovate EBD concepts; Step Five: develop a hypothesis; and Step Six: collect baseline performance measures. See the Evidence-Based Design Tab for detail about the EBD activities during this phase.

Design Activities

See Evidence Based Design tab for EBD activities during this phase

Continue Conceptual Diagramming (C, D)

Bubble or block drawings, starts in pre-design.

Begin Transition Planning (C,D)

A process of planning, organizing and managing critical tasks to be completed for the safe move and full functionality on the first day.

Select Specialty Consultants (C,D)

Expertise for specific functions, such as Lean processes, sustainability, wayfinding, etc. Select consultants based on unique needs of the clinic.

Schematic Design (C,D,R)

Preliminary building plans, elevations, sections, perspective sketches, statistical summary of building characteristics, and outline specifications.

Design Development (C,D,R)

A clear and well-coordinated description of every design aspect of the building including actual space dimensions, mechanical, plumbing, electrical, fire protection systems, and preliminary specifications.

Permit Process (C,D,R)

Regulatory, governmental, or third-party approvals. Understand requirements for obtaining certificate of occupancy or use permit.

Zoning/Use Processing (C,D,R)

Local requirements established for use, size (footprint and height), parking etc. Get approvals from local zoning authorities.

Furniture, Fixtures, Equipment (FFE) & Technology Planning (C,R)

Moveable/attachable items, furniture, medical, office equipment, computers, telephone, security systems. Many items are not coordinated by the design team, but by the owner.

Purchasing Plan (C,R)

Purchase of items not included in GC (General Contractor) contract - often surrounding FFE.

Construction Documents (C,R)

Final and complete drawings and specifications including all work by the builder and by others, actual construction cost estimates based on sub-contractor bids.

Continue Process Improvement (C)

Workflows not fully evaluated during pre-design should be finalized. As design progresses, process improvement should include development of training for staff to prepare them to work with the new processes and environment.

Value Engineering (C)

"Value Engineering" (or more broadly, "value enhanced design") is a widely accepted approach to identifying areas for cost savings in the building design by considering less expensive alternatives. A related activity is "design alternatives", a process of considering design options. This approach enables you to build the facility within the constraints of your budget, but allows for future growth without compromising the project's design.

Early Permit-Third Party Approvals (C)

Typically there are three major types of entities that will review the project and provide approvals: planning and zoning, building permit and life safety, and health. It is important to understand early on the types of approvals that might be needed for the project and the time involved in obtaining these approvals.

Bid and Award-May be phased based on contract type (C,D,R)

The process of selecting the builder through a competitive bidding process that may be required based on the source of funds. Depending on the process selected, contracts can be awarded to either a general contractor, construction management, design/build firm, or a turnkey developer.

Evidence-Based Design Activities

Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition

EBD Step 5: Develop a Hypothesis

The team identifies specific topic(s) for research and translates selected research topics into hypothesis(ses) about the relationships between design solution(s) and targeted outcome(s). Not every hypothesis needs to become a formal research project, and the organization should establish how many measures are already collected as part of a standard operating or reporting process.

Identify selected research topics for your project (P,D,R)

The project team creates criteria for evaluating, narrowing down, and determining research topics. Considerations should include how relevant topics are to organizational goals and what constraints (such as resourcesor funding) that would limit advancing the research.

Define the problem statement and research questions (P,D,R)

The team may be interested in understanding more about a broad topic, such as communication technology and the built environment, but there are many ways this might be considered. The project team divides research topics into manageable subtopics and formally documents research questions and problem statements.

Develop hypotheses (P,D,R)

The project team takes the research questions, the previously identified relationship between design solution (independent variable), and targeted outcome (dependent variable) and develops hypothesis statements. It is important to consider what variables (e.g. staff education, changes in organizational culture) other than physical environment will have an effect on the outcomes.

Develop research plan (P,R)

The project team identifies research methodology, metrics, funding, personnel, procedures, timeline, and obtains Institutional Review Board (IRB) approvals if needed (an independent review to consider the ethics of the project and ensure the rights and welfare of human subjects are protected). This may be as simple as collecting existing metrics used by the organization or be a more controlled study requiring outside resources and expertise.

From a clinic perspective, having a team member familiar with evidence-based design or research will help you understand where outside resources and expertise may be required. There may be existing tools and methods available to use, but there may also be new material to be developed. If the clinic is associated with a hospital, there may be an identified process to work through the hospital’s IRB protocols. However, where an affiliation does not exist, there are independent IRBs that approve individual projects. Unlike clinical trials that have a direct clinical impact on patients, research surrounding the built environment is usually considered less invasive, and most often is considered as part of an expedited review process. Most peer-reviewed journals require IRB approvals to publish results.

FAQs

Print FAQs

How do I know what to expect during design?

Ask your design team to develop a detailed schedule outlining major milestones for completion of the different design phases and the related subtasks. Make sure your obligations for attending meetings, providing information, conducting reviews, and approving plans are included in the schedule so you can schedule your resources. Have the design team outline specific items that are not included in their contract so there are no surprises as the design phase draws to a close. These items still require coordination with the design team, so it is important to know how items “Not in Contract” (NIC) are integrated into the schedule. Familiarize yourself with some of the resources on this site to get a better sense of what happens during design.

What are the differences between different project delivery approaches?

The traditional design-bid-build process is where the Owner contracts with separate entities for each the design and construction of a project. As the most traditional approach, it is well understood, and the design team acts to protect the Owner’s interests. The disadvantage is the ability to work directly with a construction expert on costing and constructability.
A design-build approach uses one firm to design the project and construct it, so one benefit is a sole point of responsibility, as well as cost and time savings potential. It can be a more complex process and may be subject to a less balanced view.
A construction manager is engaged early in the process and acts as the Owner’s representative providing schedule control, cost control, and coordination in providing or procuring planning, design, and construction services. A CM typically guarantees the price and schedule. A CM provides an extended set of resources for the Owner and can provide assistance with purchasing plans and other items not included in a traditional contract. There is potential for improved constructability, The CM assuming any level of risk will equate to an additional cost, and it is important for the partners to trust one another.
A turn-key development project is where the project is constructed by a developer and sold or turned over to a buyer in a ready-to-use condition. There may be a certain lack of control during this process, although it is dependent upon when and how the contract is established. The advantage is that the team usually works together on a consistent basis and can provide an accelerated schedule and some cost benefits.

What are some of permits I need to consider ?

There are several types of permits to consider during design, and they typically occur at different point in the process. 1) Local planning and zoning codes typically regulate lot size, site layout, building height restrictions, land use, setbacks (from the street), parking, historical landmarks, landscaping, open spaces, and the ratio of building size to lot/site size. These are considered at the onset of the project, even prior to site selection. 2) Building and safety codes regulate structural and foundation matters, construction materials, fireproofing, heating, ventilation and air conditioning systems (HVAC), plumbing fixtures and installation, electrical installation, and emergency egress. These codes must be followed during the design of the building, and are typically reviewed for compliance by state officials prior to construction. 3) Health: This commission (or authority) regulates health and safety issues and may be established by local, state, and/or federal regulatory authorities.

Resources

Print Resources

Breaking Ground: A comprehensive planning guide for health center projects

Created by NCB Capital Impact. Phases and activities related to this resource include:

Organizational Readiness

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Develop community awareness/engagement
Develop the business plan (Sect VII)
Development of project budget
Explore various financing options
Develop a preliminary project schedule
Hire a project manager and architect (Sect IV)

Pre-Design

Determine financial feasability
Conduct a market needs analysis and assessment
Select/survey sites and evaluate space availability (Sect IV.b)
Select an attorney, architect/interior designer, contractor and construction manager
Establish the remaining project team
Property aquisition/site control
Refine project budget/schedule (Sect VIII)

Design

Continue conceptual diagramming
Design development
Permit process
Zoning/use processing
Furniture, fixtures, equipment (FFE) and technology planning
Purchasing plan
Construction documents
Value engineering (p. 33)
Early permit - third party approvals (p. 40-41)
Bid and award - this may be phased, based on contract type

Construction

Conduct construction inspection and surveillance (p. 43-49)
Create the punch list (p. 55)

CHD White Paper: New Models of Care Delivery

Phases and activities related to this resource include:

Pre-Design

Select/survey site and evaluate space availability

Design

Continue conceptual diagramming
Schematic design
Design development
Furniture, fixtures, equipment (FFE) and technology planning

CHD White Paper: Culture

Phases and activities related to this resource include:

Pre-Design

Space function/flow analysis

Design

Continue conceptual diagramming
Design development
Furniture, fixtures, equipment (FFE) and technology planning

Whole Building Design Guide - Outpatient Clinic

The WBDG is the only web-based portal providing government and industry practitioners with one-stop access to up-to-date information on a wide range of building-related guidance, criteria and technology from a 'whole buildings' perspective. Currently organized into three major categories—Design Guidance, Project Management and Operations & Maintenance—at the heart of the WBDG are Resource Pages, reductive summaries on particular topics. Phases and resources specific to this resource include:

Design

Design development
Early permit-third party approvals

Authored by Jain Malkin. Phases and activities related to this resource include:

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

Hospital transition planning at Womack Army Medical Center, Fort Bragg, North Carolina

Authored by Canfield, B.T. Phases and activities related to this resource include:

Design

Begin transition planning

An owner’s guide to construction management.

Created by Construction Management Association of America (CMAA). Phases and activities related to this resource include:

Pre-Design

Select an attorney, architect/interior designer, contractor and construction manager

Design

Construction

Establish project controls
Substantial completion
Notice of completion
Final completion

What to Look for When Hiring a Consultant.

Guidlines and questions to ask when hiring a consultant. Phases and activities related to this resource include:

Design

Select specialty consultants

EDAC Study Guide 3

Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process.

Phases and activities related to this resource include:

Organizational Readiness

Pre-Design

Evaluate work flow
Start conceptual diagramming

Design

Continue conceptual diagramming
Design development
Bid and award-this may be phased based on contract type

Construction

Substantial completion
Final completion

Occupancy

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

Created by USGBC, last updated in May 2011. The phases and activities related to this resource include:

Organizational Readiness

Develop community awareness/engagment

Pre-Design

Select/survey sites and evaluate space availability
Plan and program

Design

Design development
Furniture, fixtures, equipment (FFE) and technology planning

VA Building and Interior Design Guidelines (multiple resources)

Created by the Veterans Administration. The attached files are guidlines for working with the VA in primary care settings. Phases and activities that relate to these resources include:

Organizational Readiness

Conduct allocation planning/preliminary space assessment
Site considerations (note narrative)

Pre-Design

Conduct a market needs analysis and assessment
Create space function/flow analysis
Plan and program

Design

Continue conceptual diagramming
Design development
Furniture fixtures, equipment (FFE) and technology planning

Labs for the 21st Century: Construction Documents

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process with a focus on sustainability. This resource is specific to the construction documents activity within the design phase.

Design

Construction document

Labs for the 21st Century: Design Development

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process with a focus on sustainability. This resource is specific to the design development activity within the Design phase.

Design

Design development

Labs for the 21st Century: Schematic Design

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process with a focus on sustainability. This resources is specific to Schematic Design. The Phases and actives relevant to this resource include:

Design

Schematic design

Facility Expansion & Renovation Planning for Capital Projects & Campaigns

Created by Gates Family Foundation. Phases and Activities applicable to this resource include:

Organizational Readiness

Conduct operational planning
Develop community awareness/engagement
Develop a business plan
Development of project budget
Explore various funding options

Pre-Design

Determine financial feasability
Start a capital campaign feasibility study
Develop a capital process/fiscal planning
Continue community engagement and collaboration
Refine project budget and schedule

Design

Design development

Report from the Field: Insights by Community Clinics on Information Technology Adoption

Created by the the Comunnity Clinics Initiative. Phases and Activities applicable to this resource include:

Organizational Readiness

Create a business plan

Pre-Design

Evaluate work flow
Refine project budget and scope

Design

Design development

Checklist: Sustainable Community Health Center Renovations

Created by Capital Link.

Phases and Activities applicable to this resource include:

Pre-Design

Select/survey sites and evaluate space availability

Design

Design development

Self-Assessment of Organizational Readiness to Develop

Created by New York State Division of Housing and Community Renewal (DHCR)/Franke Consulting Group.

FGI Guidelines for Design and Construction of Health Care Facilities

Created by the Facility Guidelines Institute, 2010 edition. There is a read only version of the guidelines at the bottom of the linked page. Phases and Activities applicable to this resource include:

Pre-Design

Select/survey sites and evaluate space availability
Property aquisition/site control
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Permit process
Zoning/use processing
Construction documents

Construction

Notice of completion
Final completion
Commissiong phase

Occupancy

Certificate of occupancy
Licensing

Outpatient Clinic: Whole Building Design Guide

Developed by the Whole Building Design Guide a program of the National Institute of Building Sciences.

Phases and Activities applicable to this resource include:

Pre-Design

Plan and program

Design

Schematic design

A free resource from Capital Link and Primary Care Development Corporation on developing a health center. Phases and Activities applicable to this resource include:

Organizational Readines

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Create project organizational leadership
Development of project budget
Explore various financing options
Consider sites (see chapter 5)
Develop a preliminary project schedule (see chapter 2, and Appendix B)
Hire a project manager and architect

Pre-Design

Determine financial feasability
Select/survey sites and evaluate space availability (see chapter 5)
Select an attorney, architect/interior designer, contractor and construction manager (see chapter 3-4, 6 and Appendix D)
Establish the remaining project team (see chapter 4, Appedix D and E)
Property aquisition/site control
Plan and program
Refine project budget/schedule
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Construction documents
Bid and award - this may be phased based on project type (see chapter 7)

Construction

Notice of completion
Final completion
Transition planning

Clinic Examples

Print Clinic Examples

Thundermist Health Center

Unique feature: New medical model of admission/reception office

Through involvement with the Institute for Healthcare Improvement's Re-designing the...

Clinica Sierra Vista

With 16 health centers and 54 different locations, Clinica Sierra Vista provides health care services to a large, underserved Hispanic population spread over 6,000 square miles. According to Doug...

Irving Health Center

Parkland Health & Hospital System and their Community Oriented Primary Care division (COPC), are a group of outpatient clinics, including 11 facilities and 11 youth and family-school based...

Bolinas Community Health Center

Bolinas is a town in Marin County at the southern tip of the Point Reyes National Seashore. It is 30 miles north of San Francisco and is...

Anchorage Native Primary Care Clinic

For the past 10 years, Southcentral Foundation has been revisiting the design process for their Anchorage Native Primary Care Clinic. In 2009, 80,000 square feet was added. Informing the design is...

La Maestra Community Health Clinic

Unique feature: Pursuing Gold Level LEED Certification

La Maestra Community Health Centers, located in the heart of City Heights in central San Diego,...

Construction

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What is Construction?

There are several approaches to constructing a building. Using a design-build or construction management approach means the contractor will already be well-versed in your project. In a traditional design-bid-build process, the project is put out to bid, and a general contractor is selected according to pre-established factors, such as experience, schedule, and cost.

During the construction phase, the goal of the project team is to monitor the implementation of the design into construction to ensure that the original intent has not been compromised. Activities occurring during construction that are led by the healthcare organization include: launching internal readiness and process improvement plans, obtaining zoning and use permits, establishing early permit and third party approvals, and beginning transition planning, and obtaining the Certificate of Occupancy (CO).

Construction Activities

Activities developed during this phase that are design team-led processes include: coordinating construction administration documents, developing punch lists, and completing project close-out.

Evidence-Based Design

The team should monitor implementation of design (Step Seven) to ensure EBD innovations are implemented as envisioned during the design phase.

Design Activities

See Evidence Based Design tab for EBD activities during this phase

Internal Readiness (C)

A related term is operational readiness: an organization is operationally ready to provide care and services if it has the right people at the right place at the right time, working with the right equipment and technology in accordance with the right policies and protocols.

Create an operations and maintenance manual (C)

The purpose of the manual is to maintain all key information related to the project in a single location, so that once the development team has been disbanded, the clinic staff has the information necessary to manage the building.

Establish Project Controls (C)

Effective management of the project includes maintenance of project correspondence, conducting progress meeting, handling submittals and requests for information, documentation of progress, review of pay requests, schedule reviews and schedule updates.

Conduct Change Order Reviews (C,D)

This involves negotiation of change orders with the contractor, coordination with the designer over design changes, determination of responsibility for changed conditions or coordination conflict, and review of price and schedule changes.

Start Project Closeout Planning (C)

Review the project to ensure orderly and timely completion, including development of punchlists; monitoring of implementation, training and warranty periods; resolution of outstanding issues; review and analysis of claims or disputed issues.

Conduct Construction Inspection and Surveillance (C,D)

The CM and/or architect usually examines project performance on a continuous or periodic basis to review progress, ensure compliance with specifications and plans, to review housekeeping and safety issues.

Create the Punch List (C,D)

When the project is nearing completion, the architect will conduct a walk-through with the contractor, project manager and clinic representative, creating what is known as the “punch-list,” unfinished tasks that are listed as conditions to be completed by the contractor prior to final payment.

Substantial Completion (C,D)

Substantial completion is evaluated by the architect and is where the Owner assumes responsibility for the building. It is set from the beginning of construction, and is significant as it is a transfer point of risk and liability from the Contractor to the Owner. It is the beginning of project closeout, but work is still required, such as punch list items.

Notice of completion (C)

Part of a state's mechanics' lien law system. Signed by the owner, it is legally recorded with the proper authority within 10 days after completion of construction.

Final Completion (C,D)

This is after the punch list work is complete, and after the owner, the builder, the architect, and often the lender make a final inspection of the site. When the final inspection is successfully completed, the architect issues a certificate for final payment, allowing the builder to collect payments still due.

Transition Planning (Also Phasing, Swing Space) (C)

Establish the activation and move plan to determine the specific of how the new facility or renovation will be operational on Day One with considerations such a staff moves, equipment moves, use of temporary space, and technology testing.

Commissioning Phase (C)

Commissioning ensures that upon occupancy, the new building systems (HVAC, lighting, water) operate as intended and that building staff are prepared to operate and maintain its systems and equipment. Enhanced commissioning can include additional items.

Project Close Out (C)

Project closeout is initiated when the contractor notifies the Owner, that the building is sufficiently completed (according to the Certificate of Substantial Completion) and is ready for occupancy. The closeout includes resolution of change orders and the final payment, completion of punch-list items, training and maintenance manuals/warranties for building systems, and the creation of lien waivers.

Evidence-Based Design Activities

EBD Step 7: Monitor Implementation of Design & Construction

As construction starts, it is the role of the project team to monitor the EBD interventions to ensure that the original intent has not been compromised. If alternates or substitutions are proposed to reduce costs, it is essential to refer to the project’s EBD goals and objectives to ensure that the integrity of the project is maintained while the project is made more cost effective.

Maintain and finalize the research plan (P,R)

The research plan describes all the key components of a planned research study - including the problem statement, research questions and hypotheses, methods, metrics, tools, workplan and budget. This should be clearly communicated to staff that will be affected by the study – either through direct participation or indirectly by others collecting data in their work areas.

Continue internal readiness/ process improvement activities (P,R)

During the visioning, planning and design phases of the project, future process requirements were discussed at a macro level, however, staff training surrounding new processes and technology changes is essential to achieve the project goals.

Describe project changes (P,R)

Any design changes that are incorporated during the construction stage should be documented with indications of possible impacts on patient and staff outcomes.

FAQs

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What activities should the CM be expected to undertake during the life of the project?

There are two types of Construction Managers (CMs). Through an agency CM, construction cost management is a fee-based service in which CM is responsible exclusively to the owner and acts in the owner's interests at every stage of the project. The construction manager offers advice on matters such as:

Optimum use of available funds;
Control of the scope of the work;
Project scheduling;
Optimum use of design and construction firms' skills and talents;
Avoidance of delays, changes and disputes;
Enhancing project design and construction quality;
Optimum flexibility in contracting and procurement;
Cash flow Management.

An Agency CM provides management of every stage of the project, beginning with the original concept and project definition and can represent the owner by helping to select the design team as well as the construction team and manage the design preventing scope creep, helping the owner stay within a pre-determined budget by performing Value Engineering, Cost/Benefit Analysis and Best Value Comparisons.

A second type of CM is a CM at-risk. This is a delivery method which entails a commitment by the construction manager to deliver the project within a Guaranteed Maximum Price (GMP. The construction manager acts as consultant to the owner in the development and design phases, (often referred to as "Preconstruction Services"), but as the equivalent of a general contractor during the construction phase. When a construction manager is bound to a GMP, the most fundamental character of the relationship is changed. In addition to acting in the owner's interest, the construction manager must manage and control construction costs to not exceed the GMP. (Source: adapted from http://en.wikipedia.org/wiki/Construction_management)

What is in Operational Readiness?

Operational readiness includes:

Redesigned models of patient care and workflow
Human resources strategy including physician strategy
IT/IS and telecom strategy and implementation
Opening day definition and ramp down and up plans
Financial plans and operating budget
Stakeholder relations and meeting expectations
Internal and external communications
Orientation and training

Related activities include a change readiness assessment that can be conducted to understand barriers to change. This includes which stakeholder groups are most resistant to change, their specific concerns, and how those concerns can be addressed. It also provides a quantitative measure to monitor readiness and alignment over time

Resources

Print Resources

An Owners Guide to Construction Management

Created by the Construction Management Association of America (CMAA). The phases and activities related to this resource include:

Construction

Conduct construction inspection and surveillance
Substantial completion
Notice of completion
Final completion

Construction Process Planning and Mangaement: An owners guide to successful projcts

Authored by Sydney M. Levy. Phases and activities related to this resource include:

Construction

Conduct construction inspection and surveillance
Substaintial completion
Notice of completion
Final completion

Breaking Ground: A comprehensive planning guide for health center projects

Created by NCB Capital Impact. Phases and activities related to this resource include:

Organizational Readiness

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Develop community awareness/engagement
Develop the business plan (Sect VII)
Development of project budget
Explore various financing options
Develop a preliminary project schedule
Hire a project manager and architect (Sect IV)

Pre-Design

Determine financial feasability
Conduct a market needs analysis and assessment
Select/survey sites and evaluate space availability (Sect IV.b)
Select an attorney, architect/interior designer, contractor and construction manager
Establish the remaining project team
Property aquisition/site control
Refine project budget/schedule (Sect VIII)

Design

Continue conceptual diagramming
Design development
Permit process
Zoning/use processing
Furniture, fixtures, equipment (FFE) and technology planning
Purchasing plan
Construction documents
Value engineering (p. 33)
Early permit - third party approvals (p. 40-41)
Bid and award - this may be phased, based on contract type

Construction

Conduct construction inspection and surveillance (p. 43-49)
Create the punch list (p. 55)

Pre-Move Checklist: Action items needed to open a new clinical facility

Created by Clinica Sierra Vista. Phases and activites related to this resource include:
Construction

Transition planning
Project close out

Occupancy

Marketing/Outreach planning

An owner’s guide to construction management.

Created by Construction Management Association of America (CMAA). Phases and activities related to this resource include:

Pre-Design

Select an attorney, architect/interior designer, contractor and construction manager

Design

Construction

Establish project controls
Substantial completion
Notice of completion
Final completion

EDAC Study Guide 3

Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process.

Phases and activities related to this resource include:

Organizational Readiness

Pre-Design

Evaluate work flow
Start conceptual diagramming

Design

Continue conceptual diagramming
Design development
Bid and award-this may be phased based on contract type

Construction

Substantial completion
Final completion

Occupancy

Labs for the 21st Century: Acceptance and Close Out

Created by Labs for the 21st Century/EPA/DoE and covers the entire design process with a focus on sustainability. Phases and activities associated with this resource include:

Construction

Commissioning phase

Who Moved the Finish Line? Redefining Readiness in a World Obsessed with Go-Live

Created by Deloitte. Phases and activities included in this phase include:

Organizational Readiness

Conduct operational planning
Determine staffing needs
Develop a business plan
Plan for the project mission/vision

Construction

Internal readiness

Self-Assessment of Organizational Readiness to Develop

Created by New York State Division of Housing and Community Renewal (DHCR)/Franke Consulting Group.

FGI Guidelines for Design and Construction of Health Care Facilities

Created by the Facility Guidelines Institute, 2010 edition. There is a read only version of the guidelines at the bottom of the linked page. Phases and Activities applicable to this resource include:

Pre-Design

Select/survey sites and evaluate space availability
Property aquisition/site control
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Permit process
Zoning/use processing
Construction documents

Construction

Notice of completion
Final completion
Commissiong phase

Occupancy

Certificate of occupancy
Licensing

A free resource from Capital Link and Primary Care Development Corporation on developing a health center. Phases and Activities applicable to this resource include:

Organizational Readines

Conduct operational planning
Conduct allocation planning/preliminary space assessment
Finalize strategic planning
Create project organizational leadership
Development of project budget
Explore various financing options
Consider sites (see chapter 5)
Develop a preliminary project schedule (see chapter 2, and Appendix B)
Hire a project manager and architect

Pre-Design

Determine financial feasability
Select/survey sites and evaluate space availability (see chapter 5)
Select an attorney, architect/interior designer, contractor and construction manager (see chapter 3-4, 6 and Appendix D)
Establish the remaining project team (see chapter 4, Appedix D and E)
Property aquisition/site control
Plan and program
Refine project budget/schedule
Start conceptual diagraming

Design

Continue conceptual diagraming
Schematic design
Design development
Construction documents
Bid and award - this may be phased based on project type (see chapter 7)

Construction

Notice of completion
Final completion
Transition planning

Clinic Examples

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Clinica Sierra Vista

With 16 health centers and 54 different locations, Clinica Sierra Vista provides health care services to a large, underserved Hispanic population spread over 6,000 square miles. According to Doug...

La Clinica de la Raza at Fruitvale Transit Village

Unique feature: The Clinica de la Raza Community Health Center is a component of a transit-based development village that provides physical renewal and economic...

Occupancy

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What is Occupancy?

After construction is complete, departments and staff are moved into the new facility and/or renovated space for a fully operational facility. While it is encouraged to engage staff throughout the entire design process, it is crucial to provide an orientation to the new facility and/or renovated space, its design features, and equipment to improve the transition from old practices to new.

Occupancy Activities

Activities occurring during occupancy that are led by the healthcare organization include: obtaining feedback from neighborhood leaders, performing community outreach, and planning marketing activities. Activities occurring during occupancy that are led by the design team include licensing.

Evidence-Based Design

In an EBD process, data is often collected after occupancy to evaluate whether hypothesized outcomes have been achieved. After you occupy the building you will complete Step Eight: post-occupancy evaluation.

Design Activities

See Evidence Based Design tab for EBD activities during this phase

Certificate of Occupancy (C,R)

Obtain certificate of occupancy; identify and resolve potential problems; make adjustments and modifications when needed.

Licensing (C,R)

Coordination of inspection and licensure reviews; If LEED status was pursued, finalize the LEED certification process - complete all documentation, checklist, LEED credit templates, project narrative; submit documentation to USGBC.

Community Outreach/ Feedback (C,R)

Performing community outreach; notify the local community about the opening of the new facility; obtain feedback from neighborhood leaders.

Marketing/ Outreach Planning (C)

Conduct open-house and marketing activities.

Run Throughs (C)

Prior to accepting patients, it is helpful to have the staff practice typical functions and scenarios so they are not performing basic tasks for the first time where patient care is involved.

Evidence-Based Design Activities

How can the community feedback be obtained and incorporated in operation and facility modifications?

EBD Step 8: Measure Post-Occupancy Performance Results

The final stage of design process is post-occupancy evaluation (POE). This is the time to measure and share the results from your project based on the goals and hypotheses developed at the beginning of the project.

Get IRB Approval (P,R)

If not already completed, the research team prepares materials for review by IRB (local or independent) for studies involving human participants, revises research plan based on IRB feedback, and obtains IRB approval.

Data Collection (P,R)

The research team coordinates with healthcare facility management and staff to collect existing and new data; adjusts data collection methods and the timeline when data is needed. In new facilities, at least six months should pass before data collection is started to allow staff to acclimate to the new environment and adjust to any process changes.

Analyze Data (P,R)

The research team analyzes data using appropriate analytic tools; validates or refutes the hypothesis(ses). The most appropriate methods for analysis will depend on the type of study.

Share Results (P,R)

The research team writes reports of research findings anddisseminates at appropriate venues, such as conferences, trade publications, or peer-reviewed journals. In an evidence-based design project, findings shoul include design recommendations – how the results can be applied to practice. Limitations should be identified, including confounding factors such as operational changes or other initiatives that may have influenced outcomes.

FAQs

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Feedback can be obtained from public meetings, interviews, focus groups, or surveys. Opinions should be evaluated by a team for the impact on both operations and the patient experience. There are often suggestions which have a minimal impact and little cost to implement, but other suggestions may be out of scope from a financial or strategic perspective. Expectations should be set relative to how suggestions will be evaluated, and in some instances it will be important to follow up directly with those making suggestions to ensure they know their opinions are heard and valued, even if not implemented.

Is it necessary to obtain a temporary certification of occupancy?

A Temporary Certificate of Occupancy (TCO) is for a temporary period of time and is usually obtained when there is a certain portion of the building the is determined to be habitable while another section is still under construction, or where minor construction is still underway, but it is safe for non-construction personnel to occupy the area.

What should be prepared for the inspection and application for CO according to local government?

The procedure and requirements for the Certificate of Occupancy (CO) vary widely from jurisdiction to jurisdiction, but this information is often available online. There are typically timeframes associated with both the time from the request for an inspection, as well as the intended occupancy date. The inspection request is made by the Contractor, the Owner, or the Owner’s representative.

Resources

Print Resources

Safety-Net Dental Clinic Manual - Marketing/outreach plan

Marketing dental services to low income/underserved populations may seem unnecessary, considering that most safety net clinic patients have no other places to obtain dental care and most clinics have long waiting lists for appointments. However, lenders don't necessarily know that. The safety net dental clinic equivalent of a for-profit business "promotion" is the clinic's "outreach" to attract patients. Generally, this amounts to just getting the word out when the clinic first opens. The outreach plan should demonstrate to lenders and others that the organization's services will be adequately utilized.

Phases and activities related to this resource include:

Occupancy

Marketing/outreach planning

Retail Clinics: Six state approaches to regulation and licensing

Created by the California HealthCare Foundation. Phases and activities related to this resource include:

Occupancy

Liscencing

California's Safety-net Clinics: A Primer

Created by the California HealthCare Foundation. Phases and activities related to this resource inlcude:

Organizational Readiness

Development of project budget
Explore various financing options

Occupancy

Liscensing

Pre-Move Checklist: Action items needed to open a new clinical facility

Created by Clinica Sierra Vista. Phases and activites related to this resource include:
Construction

Transition planning
Project close out

Occupancy

Marketing/Outreach planning

EDAC Study Guide 3

Study Guide 3: Integrating Evidence-Based Design: Practicing the Healthcare Design Process.