Playing devil's advocate is a helluva job

Part of being an architect (one of the many parts they don't tell you about in college) is that you have to occasionally save your client from themselves. This is not always easy, and rarely is it fun. We've had to do that recently with Tumbleweed County Medical Center (TCMC), and it made for a momentarily tense meeting.

TCMC is remodeling their surgery department, a project which I first spoke about here, and we wrapped up our initial space planning and pricing assessments last week and presented them to TCMC's executive staff (CEO, CFO, and CNO [Chief Nursing Officer]) and staff (facility manager, infection control staff, IT and security, and actual surgery nurses and an occasional physician who can take a break from surgery and drop by). Well, what happened is we came up with two plans: one that involved them just renovating in place and taking over a couple of nearby rooms in the hospital in order to renovate their department and make it useable as well as code-compliant, and another that invovled adding onto the outside wall of the existing surgery department and locating some program (i.e., rooms that you need in a department) there. We then listed pros and cons of the two plans, and it was pretty clear to us that the expansion+ renovation plan was better for TCMC than the renovation-only plan. Problem is, we knew it was likely going to cost more.

We have a contractor already on board, and the cost estimator from the contractor took our plans and figured out the costs associated with them. And I mean he really figured them out: because we gave him a 3D model instead of just some flat paper (or 2D CAD) drawings, he was able to see how much drywall and how many studs are in the drawings we made, what area of bricks, about how much ductwork, and so on. The contractor's construction estimate showed that the renovation + addition option cost about 20% more than the renovation-only option. We winced a bit, but we also felt like the estimates were good ones that the contractor could stand behind for a reasonable amount of time and had included proper escalation (i.e., inflation over the coming months that would make the construction costs go up) and contingency (the money you use to cover the stuff you didn't know was in the walls or suddenly go 'oh shit!' over during the course of construction).

So, we presented the plans to TCMC's executives and the users (facilities, surgery staff, and IT) and revealed our numbers. Wes, the project executive for Avanta, was there with Akira, his new Avanta project manager who handles a lot of Wes' projects. (So far I like Akira fine, but my jury is out on Wes. He's a hard dude to read.) Akira took the contractor's construction costs numbers and put them into a larger spreadsheet that Avanta uses to calculate total project costs. For example, the contractor's numbers don't include costs for medical equipment purchase and installation, nor does it include furniture or IT cabling and hook-up or asbestos removal. Avanta also included some slightly higher-than-average escalation and contingency upon contingency. When Avanta was done, their project costs had nearly doubled the contractor's construction costs. That felt kinda right but kinda weird at the same time. When all was said and done, the renovation-only project costs were just under the total project budget, and the renovation + addition project costs were about 14% over the total project budget. Everyone sat for a few seconds and let it sink in.

Then, Wes slightly shrugged and sat back in his seat and said, "Well, looks like we have to renovate only."

There was another small silence, and the CEO, a lovely woman in her mid-40s who looks like she'd be more at home in a PTA meeting than a boardroom, suddenly spoke up and showed everyone just why she belonged in that boardroom. "There's no question that the renovation-and-addition is the best bet for us," she began. "It gives us flexibility to grow in the future. We have two questions now: how can we reduce the gap between what it costs and what we have, and can we ask the TCMC board for a little more if we narrow that gap?"

Howie and I exchanged a quick look. Did TCMC's board have enough money? Wait--was all the budget money Avanta's money or TCMC's? Turns out, it was TCMC's board that allocated these funds 18 months ago, not Avanta. So why did Wes suddenly look so startled across the room when the CEO spoke up? Isn't his job to make the hospital's facility work well with regard to its physical appearance and operation?

A scrub nurse stood up at the back of the room. "Look," he said urgently as he readjusted his head rag made of flame-print scrub material, "I know budgets are important and they're made to be stuck to. But what does it say to our patients if they walk into this renovation only department and see that all the post-op bays open onto each other and thre's really not a lot of privacy? What if they see that we've outgrown the space as soon as we move in? They're gonna go elswhere. They're gonna go to Hepsburg...or Wheatlands." (Note for newcomers to WAD: Howie and I did the replacement hospital at Wheatlands, and their new building is forcing a lot of other nearby facilities to upgrade their stuff or risk losing patients to them. Some people in western Kansas say "Wheatlands" as if they're about to spit.)

Wes was clearly outnumbered here, and so we began picking through Akira's numbers and discovered about $150,000 in unnecessary costs (for example, he accounted for two new anesthesia machines when TCMC only needs one, which is a savings of about $53,000). The CFO then informed us that she would call for a special session of TCMC's board to meet in a couple of weeks so that we could present both options to them, describe the pros and cons, and then have TCMC explain to their board why they need a few extra hundred thousand bucks to really give themselves the surgery department they need.

When they planned for this project 18-24 months ago, TCMC and Avanta planned on a simple in-place renovation. Even Avanta's healthcare planner in California drew up a plan that just involved renovating in place. But when Howie and I took one look at Avanta CA's plan, we could tell right away wihtout putting a scale on it that it didn't meet code--not 2006 IBC and 2006 NFPA, not AIA Healthcare Guidelines, and not ADA and ANSI. You couldn't possibly do what that guy or gal drew up and not get thumped on the head by Colorado's state health board. Their inspectors smell blood, and if they walked into a surgery department where the pre-op and post-op bays had full walls and were only 9'-6" wide, things would get real ig'nant real fast. So we at Design Associates realized that what they really needed to do is expand their space, and adding onto the building was the best way to do it. Doing so would allow them to be right sized now and in the next twenty to thirty years, which is about the most you can even kinda predict.

As we drove back from Tumbleweedville, Howie, Bosley, and I mused on the nature of the meeting that day. Bosley actually seemed a tiny bit unnerved. "I'm not trying to step on Wes' toes," he said, "but I cannot in good conscience give a client a hospital what they think they want when it's not what they really need, what would really serve their needs now and later."

"Well, yeah," Howie echoed. "Part of our job as the experts is to tell them if they're off track or expecting too much for their budget or whatever. Sometimes, that involves a reality check on scope."

"So, if this is TCMC's money," I asked Howie and Bosley, "then why was Wes doing that frozen-eye thing? Why was he instantly jumping to the 'guess-we're-renovating' bit?

Bosley shook his head. "I'm not sure about him, what his deal is. Maybe...maybe it's part of his job to keep things in line and on track and he...alluva sudden felt like we were taking a detour..." Bosley's voice trailed off as he negotiated his car around a semi on the highway. "...not sure what We's deal is...."

I nestled back into the passenger seat in Bosley's car while Howie checked his messages on his phone. I really hope we can assure Wes we're trying to help, but being the bearer of the news that we sometimes bear can be...hard to bear.