Measure twice, cut once: an intro to Tumbleweed County Medical Center

So I haven't really been discussing what I've been doing lately, and it's not because I've been unbusy. Rather, I've been busy and trying to formulate in my head how best to a) explain what I'm doing such that I don't bore you all into hoping I'll post a YouTube video of a turtle riding a skateboard and b) disguise certain elements of my projects so that I don't out myself. (In really good but completely unrelated news, Guy scored us an amazing deal on a 17" laptop, so as I type this, I'm outside in my Extreme Balcony Garden with Maddy laying in a sunbeam and Hazel walking laps and looking for the house finches that have lately taken up roost in a high corner of the balcony. Me love wireless internets.)

So, you'll recall over the July 4th weekend that we got a job that we interviewed for. That job is a surgery renovation gig at a li'l hospital called Tumbleweed County Medical Center, about 45 minutes northeast of Wheatlands. Nice enough little place--most small hospitals are full of good people doing the best they can with what they have, saving lives and comforting the unsaveable and their families. TCMC is a small hospital with one medical office building (MOB, as we call them in da biz) on its campus, hence it can call itself a "medical center" instead of just a "hospital". "Medical center" sounds more upscale than "hospital", just like "loft" sounds more upscale than "apartment." Anyway, TCMC is managed but not owned by a larger healthcare company we'll call Avanta Health. Avanta will give them some money and help them be profitable, but I'm still not sure how much of a say Avanta gets in TCMC's desicions.

The reason I bring up Avanta is twofold. One, early on in Howie's (my main boss) career with Design Associates, he worked on a hospital remodel and expansion with Avanta and ended up rubbing the Avanta Colorado project manager the wrong way. Howie was trying to build consensus and not impose a my-way-or-the-highway healthcare design on the users of that reno/expansion project, but the Avanta PM, named Wes, took Howie's constant questions to the staff ("How do patients come through your department?") as a sign of being green and ordered that Bosely remove Howie from the project. Well, ten years later, here we are, and Howie is a half-partner in DA. Ooh, look who's all growed up, Mr. PM! Ah, but that cranky PM, who later attributed some flaws in the project to DA (inaccurately so, in my opinion, but I'll spare you the details), is now the Avanta Colorado project executive. Somebody's movin' on up like George and Weezy. We've gone after work with Avanta before and didn't get it, we think in some part due to Wes' earlier prejudice/bad taste in his mouth regarding DA. So now that we finally got an Avanta job, we know we have to work at least twice or three times as hard, because a) this is a shitty economy, and b) we have to impress Wes enough to give him a better taste in his mouth regarding DA.

The second reason I bring up Avanta is because a health system changes the dynamic of design and construction projects. They provide a great deal of funding to facilities that might not otherwise be able to afford a new MRI or remodeled surgery suite or updated physical therapy department, but these systems have their own set of rules that might not work for a smaller facility at best or might not really make sense functionally at all at worst. Health systems often have templates and standards for how big different typical rooms are (an OR, an exam room, a trauma room in an ED) and what's on each wall (sharps container, paper towel dispenser, sphygmomanometer, etc.) and how those rooms are shaped (9'x11', 8'x12', etc.). When fitting those templates into an existing space built in 1960, they might not always work, and getting the health system to buy off on a variation of their template can be a reasonable process or one that makes you want to gouge your eye out with a spoon.

At any rate, Bosley, Howie, and I have gone out to Tumbleweedville to do a couple of kickoff and programming meetings with them. Part of what we do is assess utilization statistics and population and patient growth figures. For example, with a surgery department, utilization statistics are what we produce when we find out from the facility how many procedures of what kind do they do every month and how long those procedures last. We can then show a facility how much their ORs and minor procedure rooms get used. We then compare those numbers to real life. At Wheatlands, their utilization stats could only justify having one operating room, but because they could only schedule their specialty surgeons to come out at certain times of the month, they really needed two ORs for scheduling. So it goes with TCMC.

We also run utilization stats of surgery prep and recovery beds. TCMC was originally planning for only four or five of those beds total in their surgery department, but when Bosley sat down and scheduled out two surgeries and an endoscope procedure happening on the same day, he showed them that they really need at least six prep and recovery beds. Furthermore, we had to show them that maybe they could get by with their one anesthesiologist and five prep/recovery beds, but if we cap them at that in this renovation, we've screwed them (and they screw themselves) for the future. What if they start doing C-sections, or if they bring on another surgeon trying to escape the hustle and bustle of Denver, and he brings along his own second nurse anesthetist? Guess who suddenly doesn't have the room to expand in place?

So, what we've been doing these first few weeks of the project is getting the foundation right. In terms of drawings, we've been getting as-built dimensions of the existing facility (which is exhausting, and you still never get all the dimensions you thought you needed) and building a model of the existing facility in Revit (which requires looking at a CAD drawing they had from 1999, looking at the existing drawings from 1960, and checking all of these against the as-built dimensions we took). We've also been checking their needs once more against reality with the utilization stats and looking at what rooms are required by code (for example, the actual sterile/restricted area where the ORs are requires a separate housekeeping/janitor closet from the rest of the department). Plus, we've been developing a couple of different schemes we showed them in our interview that will allow them to think about different ways to do their department: what if we just renovate? What if we add on and renovate?

While all this is going on, I'm still working on FCH's surgery and ICU renovation, which is good. Busy is good.