Master Planning: Top 8 Considerations

It might be tempting to think of hospitals and large medical centers as indestructible entities that once built stay built and can be ignored.  While that is probably more or less true of the structural system, almost everything else that has been constructed has a lifespan measured in decades and will require some level of investment.  That’s just the architecture and engineering—advances in technology, increasing patient acuity, improved clinical protocols as well as strategic positioning and growth (or decline) are constantly changing and require attention.  All of this leads to master planning—determining the range of options for capital investment over time.

1. Why

Master plans come in a variety of types, from the all-inclusive A (assessment) to Z (zoning) with demographic and market demand for every service line on every site to the focused “just tell us if this is the right site” engagement.  Neither approach is necessarily better than another, but there should be consensus on the type of information desired from the master plan process (though not a pre-determination of the results and recommendations).

Challenge:  Addressing strategic and scenario questions that might challenge the status quo of where and how care is delivered.  A robust master plan will include ways of thinking about the things no one wants to think about.  Hospitals struggled with COVID-19 in part because of a reluctance to heed the warnings made by many epidemiologists that another 1918-1919 flu was probable and because addressing the inherent issue of possible disruptions to JIT supply chains didn’t seem to merit attention.

2. What

A master plan typically consists of a mid-term (seven to ten years) framework for capital investment that delivers on the imperatives of a strategic plan (if there is one), and includes an analysis of the existing facilities, phasing implications, and projected cost estimates.  Scope and square footage requirements should be driven by an understanding of the number of key rooms (e.g., patient rooms, operating rooms, etc.) which in turn should be driven by assumptions regarding utilization and operational models.  In terms of future fit, a mentor of mine once said “design a mitten not a glove.”  Master plans should have a basis for assumptions about future size requirements, but there should be allowances for wiggle room.

Opportunity:  Assess possibilities of rethinking traditional departmental organization and operations with the aim of delivering higher quality care more efficiently.

3. Who

A successful master plan requires a senior leadership champion, though the day-to-day management of the effort may be led by others.  Most master plans follow a similar pyramid model in which a very senior Executive Committee will make the final decisions based on recommendations made by a Steering Committee comprised of stakeholders with a broad range of roles and responsibilities (committee names may vary).

Suggestion:  Consider options for community engagement.  Most master plan efforts exclude community involvement for a variety of reasons (it is too early, it is too strategic, it is always something), but surely there’s value in hearing from those whose lives will be directly affected by future development.  At least think about it.

4. When

When should be driven by why.  Some institutions elect to conduct an inclusive master plan every ten years; others, either before or after every major building project.  Any significant capital investment or project that utilizes an available site should be reviewed within the context of a master plan—or run the risk of stymying future development (campus checkmate).

Recommendation:  Understand the annual operating expense of older buildings and when that expense exceeds the benefits of use, consider demolition.  An open site is an asset and doesn’t need an immediate plan to be valuable in the future.

5. Where

There’s been a great deal of talk about shifting from hospital-based care to ambulatory environments, and yet, many hospitals are still playing host to services that should go elsewhere but have been stranded due to reimbursement models, inertia, or the insistence of clinicians and managers who like having everything in-house and in one place.  The “where” is in part a question of which needs have priority:  patient convenience and preferences (and their ability to choose services based on those two factors), revenue, site capacity, operations, etc.  Including non-hospital and even non-traditional MOB/ASC sites in a master plan are likely to become increasingly important.

New greenfield sites should always include a master plan, even if it is highly conceptual and consists of little more than land use principles.

Opportunity:  Don’t let the changes forced by Covid-19 go to waste—the trends of telehealth and working from home may have an impact on everything from department location, to size and parking requirements.

6. Departmental & Service Line Master Plans

One key component of every master plan should be ensuring that key chassis departments and services—emergency, surgical, interventional, imaging, heart & vascular, and patient beds—have the space they need to evolve and grow.  Departmental master plans are often overlooked options when thinking about future development even though they may be an expedient and cost-effective way to focus on revenue generating services.   Departmental master plans may also be multi-site and should include “downstream” services such as lab and pharmacy if there is to be significant growth or change in practice.

Warning:  One good departmental master plan tends to lead to another—not a bad thing.

7. Infrastructure and Circulation

While it may be tempting to focus primarily on key departments and services, if you can’t get there from here or deliver appropriate (and increasingly required) engineering systems within the hospital, there really isn’t much point.  Periodic infrastructure assessments, if not included in periodic master plans, are a good exercise and likely to lead to initiatives that reduce energy costs, improve operations, and move an institution towards more sustainable practices (see #8 below). In reality, very few hospitals can address all the delayed maintenance and upgrade requests they would like to; it’s an endless game of reprioritizing projects, crossing fingers, and kicking the can to next year’s list.

Good and clear circulation, both horizontal and vertical, is what holds a medical campus together.  “Good” often means few turns and intuitive wayfinding, as well as separation of public (on-stage) and service (off-stage) systems.  Walt Disney learned this lesson at Disneyland and improved circulation systems at Disney World; it took planning and investment, and hospitals should do the same.

Recommendation:  Find a way to put the not inconsequential costs of both infrastructure and circulation upgrades into a context that senior leadership will understand.  A car with a bad motor can’t go very far or very fast.

8. Climate change is more than a sea change and Net Zero is coming (ready or not).

LEED has been around for more than 20 years and many organizations have at least contemplated resilience for much of the past 10 years (Super Storm Sandy flooded NYU Langone in 2012), and yet most healthcare systems have nibbled around the edges or given themselves a pass on these issues because they have been able to do so.  There is going to come a time in the next decade when this will no longer be as true.  Master plans are, by definition, about the future and perhaps it is time to stop ducking our shared responsibility to put the health back in healthcare, our campuses and communities, and the planet.