Converting a Cornfield to a Sterile Field

BY MARK F. YEAGER, AIA

In our work across the U.S. as medical specialty planners and architects, we solve difficult problems, including complex program requirements, difficult site conditions, and compressed design and construction schedules, for example. This article details one of our more unusual cases.

Several years ago, I received a call from an ambulatory surgery center (ASC) developer. He’d just been in a dispute with his design team and had terminated their contract. He wanted me to accompany him on a damage-control mission to visit a client located in a small Appalachian community to brainstorm ways to move his project forward. He agreed to buy a few hours of consulting time for ASC value-engineering that our firm is known for, and I agreed to make the trip.

We arrived at a modest building that was a former police barracks. The doctors had purchased it from the state and converted it to a medical office and a physical therapy component. We were shown to the conference room where the doctors and administrator were clearly upset because their expectations weren’t being met: the project was behind schedule, the contractor bids were significantly over budget, and the doctors were facing the probability of a delayed revenue stream from the new facility. I thought, “This is about as bad as a situation can get.”

But was I wrong. When I opened the construction documents, I began to understand why the contractors’ numbers came in sky high. And the longer I looked at the drawings, the more I realized that the project, as designed, shouldn’t be built. The few hours of consulting with the doctors and developer soon morphed into a total architectural and engineering redesign of the facility — all on the developer’s dime. It was the only option that the developer and the doctors had, short of throwing the whole mess to the lawyers.

The design called for a one-story, single-OR facility with a walk-out basement for storage and mechanical space. Curiously, the basement walls were detailed as 18-inch-thick concrete, chock full of steel reinforcement rods. It was the stoutest retaining wall detail I have ever seen for a basement wall. I knew the area was neither seismically active nor affected by unusually high-wind loads. Puzzled by the missile-silo strength of the basement walls as detailed, I asked for the results of the geotechnical report. I was informed one hadn’t been ordered.

Without an analysis of the soil-bearing qualities and a recommendation for foundation design by a geotechnical engineer, there was no basis for the design. The structural engineer tried to minimize his exposure to liability by over-designing for resistance to lateral forces that may not be present, in turn causing the contractor to waste the owner’s money on needless materials and labor. Again I thought, “This is about as bad as a situation can get.”

But I was wrong again. In the mountainous surroundings, the site was extremely sloped. The doctors had purchased the site adjacent to their medical office the year before, when it was still a corn field on the neighbor’s farm. To keep the project moving along, the owner decided to construct the septic tank and lateral field system for the future surgery facility on the rear of the lot, leaving a tightly defined area in which to place the building.

The design for the driveway was for a 15 percent slope, steep enough scrape the underside of a vehicle at the top of the ramp, and the bumpers at the bottom. Parking spaces were on a 10 percent grade, making it a certainty that a car’s passenger door, when unlatched on the downhill side, would fly open, damaging the car parked next to it. Worse, the steepness created a slip hazard for patients and staff.

We eliminated the basement, enabling us to lower the floor level by several feet in order to make the driveway and parking grades work at a reasonable slope. By eliminating the basement retaining walls and footings, and utilizing a more economical slab-on-grade foundation system, we achieved a big cost savings.

But we didn’t stop there. The floor plan in the original design was organized like a miniature hospital instead of an outpatient facility. By eliminating all the unnecessary circulation space, and with the doctors’ enthusiastic approval, we converted the captured area to an extra operating room and recovery space, and we created space for a few more chairs in the waiting room to absorb the additional demand.

We decided to replace the basement storage area with a simple expansion shell at one end of the building, creating a step in the foundation where the two floors meet. This made the overall footprint larger and, consequently, we had to use an architect’s shoehorn to make it fit among the property boundaries, zoning setbacks, the septic field, storm water detention areas, sidewalk and parking pavement, emergency power generator, condensing unit, and the pump housing for the well that would supply the water to the facility. It was tight but it worked, and we didn’t stop there.

For the exterior, the owner strongly preferred the plain look of the existing medical office. We matched the brick, the siding, and the roof pitch, and added a welcoming porte-cochere and a covered patient pick-up area.

The doctors and the developer enthusiastically approved the new design. We had saved them money, created more efficient flow patterns with additional productive space, improved the parking area, and added a covered entry and patient pickup, making for a more user-friendly building. The state department of health readily gave its approvals, and we released the construction documents for a new round of bidding.

On the day the bids came in, everyone broke out in smiles. The project had come in under budget and the owner was back on track. The project was constructed that summer. Once the doctors moved in, obtained licensure and certification, and started performing cases on a regular basis, the grievances between the doctors and the developer were greatly diminished.

Planning and designing an ASC is not a cookie-cutter operation; often problems surface that require the skilled response and expertise of a seasoned design team.

Mark F. Yeager, AIA, is a principal of Design Consultants International in Atlanta. DCI works exclusively with all medical specialties nationally, achieving superior results in planning and design of ambulatory surgery facilities and medical specialty offices.

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