Montefiore Medical Center's Ambulatory Care Center

Designs Delivered Montefiore Medical Center’s Ambulatory Care Center

Table of Contents

Ambulatory Care Centers ............................................................4 An Ambulatory Care Center for the Bronx.........................6 Unique Challenges............................................................................8 Lean Design......................................................................................... 10 Patient-Centric Design ............................................................... 12 Floor Connectivity......................................................................... 14 Surgical Environments............................................................... 16 Integrated Imaging....................................................................... 20 Mechanical Organization.......................................................... 22 Six Floors for Physician Practices ......................................24

?

Ambulatory Care Centers Except for the beds, ambulatory care centers have all the elements of a hospital, making them ideal expansion areas for health systems to provide care outside of their hospitals’ walls. Delivering the quality they are known for to a new neighborhood or cachement area is important in the new era of population health.

Ambulatory services are a critical lynch pin in the development of comprehensive, integrated care networks that can deliver services cost-effectively and achieve high levels of patient satisfaction.

Successful ambulatory care facilities are designed to maximize flow.

Architects must orchestrate a process that enables operational improvements and adjustments, while simultaneously maximizing space utilization and throughput.

Ambulatory Care Centers should sit at the heart of the healthcare experience, empowering patients with education and wellness, and providing wellintegrated, highly effective care.

Today’s facilities need to work with tomorrow’s technologies. The current and future trends in ambulatory care underscore the highgrowth, high-change nature of such facilities. These trends also highlight the need for flexible design, now and into the future, as ambulatory care centers continue to serve more people in new ways.

PAGE 4 | Designs Delivered

An Ambulatory Care Center for the Bronx Montefiore has been offering exemplary healthcare since 1884 when their first facility opened in New York City’s Upper East Side. Since then, they have built a reputation in providing a patient-centric approach to healthcare and a high standard of quality when it comes to design.

When Montefiore retained Array to provide planning and design services for the complete fit out of their new campus, we were prepared to provide a project that aligned with Montefiore’s standards. As a healthcare-exclusive firm, we understand and value designs that focus on providing better care for patients and over three decades have created a high standard in design that applies to every project within our firm.

A priority for their new campus is the ability to accommodate more patients with better healthcare. Montefiore provides healthcare services to two million people in the Bronx and Westchester County.

An ambulatory care center is central in providing affordable and accessible healthcare for the Bronx, an urban community, one of the Nation’s poorest, facing high rates of chronic and preventable diseases such as asthma, diabetes and obesity. As Montefiore’s fourth campus, the Hutchinson tower is a center of excellence with an emphasis on serving the local community—an urban community overwhelmingly characterized by health burdens and economic hardships. Providing an all-inclusive center of excellence with specialty and primary services, the Montefiore Hutchinson campus stands to become a one-stop shop for medical needs and serves as an opportunity to reduce health risks in the population. Having multiple providers housed in a center of excellence ensures better patient follow-up, communication and knowledge sharing to offer enhanced care.

Montefiore Medical Center is making healthcare accessible for an urban community. With the new campus’ central location and increased need for staff, the System’s plan is to lower the prevalence of health burdens and play a large role in easing economic burdens in the Bronx. With nearly a third of the Bronx employed in the healthcare industry, Montefiore has become the borough’s largest employer.

The Montefiore Medical Center was featured in The Advisory Board Company’s Architectural Showcase: September 2015.

“Studies show that people tend to do better when things are colorful and cheery,” says Pratibha Vemulapalli, MD, Montefiore’s Director of Preoperative Service. “When you walk into the building, it’s a huge open lobby with a lot of natural light coming in. It’s very colorful and very bright.”

- Outpatient Surgery Magazine

Montefiore Medical Center | PAGE 7

Unique Challenges The site Montefiore chose for their new medical campus, pre-zoned for business and hotel space, came slated with a building footprint intended for such use. Amending zoning laws and the existing footprint was prohibitive, especially against an aggressive schedule and a tight budget - Montefiore would gain $12.6 million in lease savings if their new campus met a significant completion milestone by December 2013. This gave Array 18 months to design and fitout an all-inclusive state-of-the-art facility with a predetermined footprint and bound by zoning laws not optimized for healthcare.

To capitalize space, Array designed a tower that utilizes the existing 12-story height zoning limit, creating a new 280,000 SF ambulatory care center. Though the tower is now one of the largest facilities of its kind in the northeast, the zoning law’s slim width allotment makes the space unique from other healthcare facilities, as floor plates are limited on each level.

Split between three floors are the ambulatory surgery services, which include 12 operating rooms, four procedure rooms, 64 recovery bays and support spaces.

This vertical configuration places an emphasis on multi-level organization and floor connectivity for equipment, materials, patients and staff to create and maintain a patientcentric design.

To maximize efficiency and safety between floors and services, Array designed an additional six elevators for a total of 10 elevators. Additional columns and footings were also needed to support the two MRIs and two CTs as well as adjustments to stair footings to allow proper separation for healthcare egress requirements.

These structural modifications and additional elevators called for early and continuous collaboration with structural engineers and project planners. To align with budget and schedule needs, we employed a Lean Design Approach to utilize 85% of the existing columns, footings and core locations.

PAGE 8 | Designs Delivered

Montefiore Medical Center | PAGE 9

Lean Design In the designing and building of Montefiore’s Hutchinson campus, a

This also expedited other field trades such as electrical

Lean Design Approach was imperative to understand how clinicians

subcontractors. Because the model so accurately reflected the actual

and staff could work—and how information and patients could

construction, snapshots of different columns could be extracted

flow—to maximize efficiency in this unique space. The impact from a

from the model, measuring distances between all columns, allowing

Lean Design Approach on quality and cost were essential to allocate

accurate off-site fabrication. This reduced the need for field sketches

resources appropriately and to stay within the project schedule.

of transitions and saved significant time.

A Lean Approach was also essential for delivering this complex

The model was developed to support actual construction sequencing.

structural project within budget and for meeting the aggressive

For example, some floors had piping completed before ductwork, while

schedule by organizing all project phases and promoting coordination

other floors had ductwork completed first. To facilitate installation, the

with the entire project team, from the owner and architect, to

model contained color-coded materials that corresponded to a color

engineers, construction manager and trade contractors. Another

when delivered to the site.

condition-determined form utilizing Lean was the knowledge that working in a single BIM model was optimal for coordination and would help avoid setbacks. This required extensive collaboration and training of the trade contractors so they were fully prepared to work with BIM technology. Dedicating collaboration time to familiarizing our team with BIM early in the project expedited construction.

With the model so integral to the design, off-site fabrication and construction of the project, it was imperative that the building reflect the BIM model exactly. Changes made in the field had to be updated in the BIM model. All copper piping one inch or larger, as well as all medical gases, and every valve and shut-off switch were modeled in the BIM model.

PAGE 10 | Designs Delivered

Collaboration among team members was critical for the success of this 280,000 SF “hospital without beds.” Team members met in a “War Room” on-site weekly. The group virtually reviewed shop drawings in the BIM model, enabling the approval of coordination drawings in half the time of a conventional project. The result was a complex project designed and built with minimal field revisions utilizing BIM to meet an extremely aggressive schedule.

Montefiore Medical Center | PAGE 11

Patient-Centric Design From the lobby all the way to the 12th floor, the design centers on the patient experience by incorporating artful details, an abundance of natural light and clear wayfinding for seamless transitions for patients, staff and materials.

During the design phase, we carefully considered multiple patient and visitor entry points from various modes of transportation. A large canopy protects the drop-off by car and a complimentary shuttle service is available from nearby train lines.

The lobby, accompanied by an open information desk and ample seating for patients and visitors, is made inviting with an 80-foot mural depicting natural landscapes lining the curved walls. Wood beams and recessed lighting line sections of the lobby ceiling, reinforcing Montefiore’s commitment to soothing design. For surgery patients, direct elevator transport from the lobby brings them to surgical prep areas and suites, offering a safe, efficient and private experience.

PAGE 12 | Designs Delivered

Waiting spaces are centrally located on surgical floors so as not to block staff workflow to and from operating spaces. With careful and thoughtful consideration, Array selected the details, such a furniture and finishes, in these spaces. Borrowing natural textures and colors and combing these with soothing accent colors provides a relaxing environment that breaks from the clinical feel of a traditional hospital. Furniture was selected to provide not only comfort but also to support Montefiore’s high quality of design. Lighting is soft and floor-to-ceiling windows spill natural light across surgical waiting areas. Cafe-like space to connect to the Internet is available.

In the children’s wing, pops of color and playful furniture create an inviting space for younger patients. Patterned walls add to the unique feel of the space while opaque, patterned glass provides privacy at individual check-in areas. There is also ample seating provided for adults.

These design elements, along with the efficient and comprehensive list of procedures and services provided all come together to represent the change in healthcare delivery and the spaces in which healthcare takes place. Montefiore represents the future in healthcare delivery, bringing affordable care to an under-served urban community in a world-class setting. The ease and comfort of the new facility is empowering the surrounding community to take charge of their healthcare needs.

“… the new tower had been carefully designed with patients in mind, with a goal of making their experiences more pleasant. The fourth-floor waiting area resembles the lobby of boutique hotel, with leather chairs and free coffee. In rooms used for MRI and CT scans, there are illuminated pictures of blue skies and trees on the ceilings.”

- The New York Times

Montefiore Medical Center | PAGE 13

Floor Connectivity Dedicated elevators enhance the floor connectivity for the ambulatory surgery patient approach. Upon valet service drop-off, patients enter and have a dedicated elevator transport them directly to the fourth floor for check-in and pre-operative services. After prep and changing, patients are transported to one of two dedicated elevators, which takes them directly to the OR floor. From the OR, patients are transported to the sunlit recovery bays, and ultimately down the dedicated elevator to their waiting car. The dedicated elevators allow surgery patients discreet entrance and exit.

When exiting the clinic floor elevators, each floor opens to a welcome center with staffed desks and kiosks, facilitating check-in and navigation.

Waiting rooms on the upper medical practice floors are centrally located to minimize foot traffic to the exam rooms. Offering online appointment registration increases patient throughput by minimizing paperwork and other check-in tasks upon patient arrival. This approach allows for a Lean flow, increased privacy and safety as well as enhances the patientcentric experience.

PAGE 14 | Designs Delivered

Montefiore Medical Center | PAGE 15

Surgical Environments SURGICAL SUITES Montefiore’s vertical configuration necessitated that the Surgical

The third floor is complete with 12 ORs; a case cart system utilized

Environment, encompassing 12 Operating Rooms, four (4) Procedure

to support procedures and is looped back to the Central Sterile

Rooms and support spaces, to be dispersed between three floors. The

Processing Department by dedicated elevator transport. A clean core

ORs are equipped with electronic bedside registration and charting

with direct vertical transport that leads directly to the clean central

for patient and staff ease as well as sliding doors with non-touch wave

sterile supply serves the ORs. With the use of dedicated patient

technology for access. ORs also have the ability to swiftly convert from

elevators, staff can transport patients from the fourth level pre-op

Level-four procedure rooms to class ‘C’ ORs based on need.

area to the OR. After recovering in the 64-bed Post-Anesthesia Recovery Unit, patients can exit the facility accompanied by a family member to a waiting car. There is also lounge space with staff support.

PAGE 16 | Designs Delivered

RECOVERY The fourth floor contains the surgery waiting, pre-op and stage-

Patient surgery prep and recovery takes place over two floors within the

two recovery space, enhanced with a four-room minor procedure

facility. In recovery, clerestory windows above each station allow patients

suite including endoscopy space. Also occupied on this floor is

to have a connection to nature as they recover from their procedure.

staff changing and sterilizing for the ORs and an elevator as well

Unique patient-centric design allows natural light to flood the semi-private

as a staff stair connection to the clean surgery suite, provided to

recovery bays to enhance the mind-body connection and encourage

maintain the one-way flow to the clean environment.

relaxation for patients. Each pre-op and recovery bay ensures patient

The design of a flexible ambulatory OR was key in allowing the most efficiency in scheduling OR block-times. At approximately

privacy with custom designs while offering an open, connected feeling with unobstructed views from the nurse station.

500 SF, the ORs are setup identically to streamline the scheduling process. All ORs and procedure rooms incorporate flexible Stonhard RTZ flooring and an integral base, greatly reducing cracking and infection control issues. The walls— covered by a fully-welded and adhered polymer—are monolithic, also reducing infection control issues, while keeping the look new and durability.

Incorporating the Kruger laminar flow ceiling system, a system with a smaller laminar over-table footprint, decreases the amount of air flowing over a patient during surgery and increases the time it takes for the surgical area to dry. This also allows a two-foot band around the laminar flow area, providing an ideal location for OR booms and a defined location for future booms or ceilingmounted equipment. A Kruger system air curtain completes the infection control protection of the surgical field.

Montefiore Medical Center | PAGE 17

CENTRAL STERILE PROCESSING Review, Review, Review: Achieving Maximum Efficiency in the Central Sterile Processing Department

Montefiore’s vertical organization of the surgical services, distributed between three floors, emphasized floor connectivity within the CSPD. Utilizing Rapid Lean design principles, we reviewed the workflow of the OR supplies in relation to the CSPD, from how the goods arrive on the floor, to breakdown and storage on the shelves.

Whether within an inpatient facility or an ambulatory center, the location, flow and size of the Central Sterile Processing Department

This review uncovered the delivery frequency of certain supplies,

(CSPD) affect adjacent spaces, as well as

their weight and footsteps taken to their shelf

a facility’s overall effectiveness. We do not

location. A flexible storage model allowed us to

stop at planning and design of the facility,

adjust the layout in the CSPD with a continuous

clients call upon our expertise during staff

improvement model (PDSA – Plan, Do, Study,

training and after occupancy to refine flow

Adjust), to achieve maximum efficiency. After

and optimize the service the Department

the first layout was completed, the staff studied

delivers internally.

it for a week. During the second review session, further adjustments were made prior to the start

Knowledge of equipment specifications

of the first surgical case.

and procedure/surgical instrumentation needs as well as our dedication to listening

Two weeks after the first surgical cases started,

to the users of each facility, provides us the

a third review session was held. After a full re-

expertise to assist our clients at all phases

supply of information and frequency of use were

of their Central Sterile process.

determined, additional adjustments were made

PAGE 18 | Designs Delivered

to the inbound supply workflow, the cart loading and cart staging work

surgical service areas with radio-frequency identification technology

flows, as well as the development of an area immediately adjacent to

will not only help in tracking where that expensive scope is located,

the clean elevator for high frequency supply replenishment. Teaching

but it will also help in tracking smaller surgical instruments reducing

the CSPD staff how to conduct a Rapid Lean session on their own

the amount of lost instruments. During the instrument purchase, the

allows them to keep aligned with the PDSA method as the future of

RFID technology can be embedded in the smallest instruments for

surgical services develops and as their needs grow.

a minimal or no-cost increase. The accidental disposal of surgical

A second and equally valuable pillar of a modern CSPD is technology.

With OR turnover times at a premium, the way the ORs are supplied and the way instruments are processed are key factors in reducing turnover times. Technology can greatly aid the staff and help manage workflow. The automation of the wash sequence and washer unloading will allow the decontamination staff to focus on the arrival

instruments during OR turnover can add up to a significant yearly cost. To avoid this, all trash, soiled and utility rooms on the OR floors are equipped with a detection system that will notify the staff if there is an instrument in the bag. This detection system is also utilized throughout the CSPD to ensure that instruments and equipment maintain their proper workflow path.

of soiled carts and the heavy particulate wash. The use of the abacus

While technology alone will not ensure the most efficient turnover

system for the prep and pack area allows the CSPD staff to have

time, proper staff education and training with the aid of technology will

greater efficiency and workflow when sorting instruments.

help to achieve the most efficient turn over time, thus enhancing the

Another technological improvement for the OR and CSPD is radio-

OR throughput model.

frequency identification (RFID) technology. As instruments pose a high dollar amount to the surgical services budget, equipping the

A Lean approach to design provided necessary insight on process and workflow to determine that the vertical stacking of surgical services would maximize efficiency.

Montefiore Medical Center | PAGE 19

Click here

to view Top 8 Considerations When Redesigning MRI Suites

Integrated Imaging When embarking on the design and planning of the Hutchinson building, Array understood that the facility would have to meet an increasing need for Imaging services with the latest technology to create a modern facility dedicated to the needs of patients and staff. The facility therefore has a full imaging suite with two MRIs, two CTs, four Radiology rooms, a mammogram suite and an ultrasound room. Distributing this technology through the facility required extensive and continual coordination between the design team at Array, Montefiore’s staff, the clinical team, equipment vendors, audio/visual vendors, MEP and structural engineers, as well as expediting consultants. The MRI and CT suites feature unique ceiling art with illuminated pictures of natural landscapes to ease patients as they undergo an imaging procedure.

PAGE 20 | Designs Delivered

Montefiore Medical Center | PAGE 21

Mechanical Organization The Mechanical Equipment Room (MER) is an integral part of any

design the ductwork? Most importantly, what are the clearances

hospital or healthcare facility; yet architects usually place the MER, or

and service access points? During concept design, the specific

the interstitial space, in a facility’s leftover space—typically between

manufacturers of the units and other items may not be finalized. So,

floors to house vital mechanical equipment—and rarely give it much

how do we correctly size the floor height so it will not be too small

design attention. However, due to Montefiore’s structure and the

– leading to coordination issues down the line – or too generous,

building’s height and width restraints dictated by the site’s zoning

wasting valuable floor height?

laws, there was no space for mechanical equipment between floors.

The design team had to reorganize the typical interstitial space in a way that would complement services within the facility while not compromising equipment space or operation.

Zoning restricts the height, so if the MER floor height needed to increase, the remaining floor heights needed to decrease to maintain the maximum building height. We reviewed several manufacturers for mechanical units and were able to short list three manufacturers

When designing the MER, several restrictions and considerations—

based on performance and criteria. As we designed the duct runs to

planning and design coordination, MER location within the building,

minimize the necessary height, we discovered that all short-listed

the MER environment, protecting adjacent areas and unit removal—

units were similar in height. We utilized the tallest unit to set the floor-

affected the process and overall design. To ensure the resulting MER

to-floor height and began to pull plan, tracing back to the fifth floor

met Montefiore’s various needs, distributing the systems was a two-

MER, where the ideal shaft locations would be throughout the building.

step process.

Utilizing BIM and coordinating with the MEP and CM enabled the

The first step involved analyzing the space that the ambulatory

design team to analyze reach properly. We then used an access

surgery program needed within the total floor space. It quickly

circle—an object used around valves, gauges, etc. to verify there are

became apparent that not only were the lower floors tight with all

no conflicts or “clashes” with the needed reach of adjacent piping,

of the program, but there was very little room for even the smallest

ductwork or conduit—to identify where duct overlaps could occur

MER closet on floors one through four or the cellar. The second step

in the MER before finally placing the unit locations, satisfying all

included analyzing the remaining floors, 5-12. The program was not at

clearances and maintenance access.

maximum capacity on these floors, presenting the possibility of having a localized MER on each floor. Based on the program analysis, the consensus was to split the building in two sections.

This lengthy process was necessary and beyond normal coordination and clash detection. Additionally, since the MER is typically adjacent to other spaces – vertically or horizontally, it is important to consider

Section 1, floors 1-5 (high acuity space), would be served by a large

the containment of sound, as well as water or glycol mixed liquids in

MER taking up 11,000 SF on the fifth floor. Section 2, the remainder

the event a pipe or fitting should leak, as this may be catastrophic for

of the building, had two MERs per floor, each at approximately 500

adjacent areas.

SF to service it. The team shuffled and aligned the areas for small MER closets on the lower floors to become the shaft locations to feed floors one through five. Multiple MER locations add redundancy in the system by not risking everything on one endeavor, enabling the ability to interconnect, providing backup capabilities to the MER plants.

At Montefiore, waterproofing the entire floor and 6” up the walls will contain leaks while floor drains allow water to escape. Moreover, the team used construction masonry units (CMU) for all walls enclosing the MER. The CMU walls provided enough density to deaden the low hum of the unit compressors and motors, preventing the sound from

Once the locations of the MERs were set, it was time to consider their

escaping into the adjacent areas. To ensure the maintenance of our

design and coordination. Healthcare facility MER designs are detailed

high Sound Transmission Criteria and that our Noise Criteria was kept

and involved, with various crossovers, interconnections and layers

low in all adjacent rooms, the team utilized acoustic doors and frames.

to harmonize. What height do the MERs need to be? How should we

PAGE 22 | Designs Delivered

“...even though it’s a medical facility, even though you’re there for care and may be in pain, the mind-body experience is incredibly important. What you holistically feel is going to translate to how well you do and how well you accept whatever news you get and whatever experience you have in the building. We want everything to be welcoming. That’s the theory behind it all.”

- Outpatient Surgery Magazine Montefiore Medical Center | PAGE 23

Six Floors for Physician Practices Montefiore’s modern design extends to the facility’s medical office space, encompassing nearly half the building. Medical office space is at the heart of the healthcare experience for patients, allowing the space and technological needs to empower them to take their health into their own hands. Due to the importance of this space, technological advancements are coupled with soothing design features.

The specialty clinics and exam rooms occupying the upper seven floors of Montefiore utilize flexible designs to increase space and enhance specialized care when needed. These upper floors were planned around modules of three exam rooms per physician’s office in addition to staff/ education workspaces. A module of three treatment rooms is also available.

The module-based design allows space to increase or decrease easily based on users’ needs. Rooms can swing from office to consult to exam room with minimal down time due to standardized configurations and provided infrastructure.

Exam rooms showcase views of the Long Island Sound, as well as offer typical exam space along with a consult area with a table, chairs and computer screen allowing medical professionals to explain test results and treatment options alongside the patient. With this flexible design, rooms can easily swing from office to exam room.

Clinical floors also feature new team centers. Every exam pod is equipped with a team center in place of a traditional nurse station to encourage better patient care and efficiency. The traditional nurse station is a centralized desk responsible for greeting patients and organizing medical charts. The team centers at Montefiore, removed from heavily trafficked areas, create two separate areas for greeting patients in a patient-centered approach. With a separate space dedicated to medical personnel, team centers also encourage knowledge-sharing between clinicians.

PAGE 24 | Designs Delivered

Montefiore Medical Center | PAGE 25

Boca Raton / Boston / Cleveland / Columbus / Dallas / New York City / Philadelphia / Washington