SHARP REES STEALY
DOWNTOWN Medical Center
Certified LEED Gold NC
avrpstudios Creative people. Smart solutions.
Western Pacific Region 2013 Design Build Awards
Summary profile AVRP Studios Inc.
Sharp Rees-Stealy Medical Group
Design / Builder Name
Mechanical Design Builder
Rudolph and Sletten Inc.
AO Reed Mechanical / DEC Engineering
Electrical Design Builder
David Jesme, DBIA Professional
Dynalectric Inc. / Sparling Engineering
Address 10955 Vista Sorrento Parkway, Suite 100
San Diego, CA 92130 858.259.6262 email@example.com
PROJECT GOALS By designing and constructing a state-of-the-art medical center that is replacing one that started providing medical service to the community in 1926. The new facility is across the street from the existing one in an historic part of the city. The design needed to be modern for today’s technology but at the same time fit within the heritage style of architecture found in the surrounding neighborhood. Also built around a 110 year old historic tree which is being protected and cared for and ultimately part of the new center. OVERALL COMPLEXITY AND DESIGN CHALLENGES The SRS Medical Center balanced an ever expanding program with a significant amount of agency required building setbacks, preservation of a 110 year old fig tree, and maintaining the language of the historic neighborhood. The center is designed to maintain an open and hospitality oriented identity. This openness caused gestural, egress, and fire suppression problems. From agency to layout, the SRS Medical Center’s design solved a series of problems and limitations with a single complex and coherent solution. PROJECT INNOVATIONS The SRS Medical Center was designed to choreograph the Sharp patient experience with caregivers’ workflow. The layout of the building is innovative in that it separates program to allow for public and caregiver circulation. Further, the Medical Center has details such as ‘family rooms’ to make the building have a warm and hospitality oriented spirit. This new layout of program for healthcare coupled with a desire to bring light though out the building yields a unique design that will be a staple precedent for future projects in healthcare.
Name of Project Sharp Rees-Stealy Downtown Medical Center
AWARD QUALIFICATIONS The design build team of Rudolph and Sletten and AVRP Studios focused on providing excellence in design build delivery to Sharp Rees-Stealy. They work together closely with open and consistent communication to reap the benefits of the design build process. The team was able to explore innovative and sustainable technology and implement them successfully in the design due to their communication strategy. The entire package yielded a design that was high quality with successful value engineering. The SRS Medical Center is a project that reflects DBIA’s vision and mission for the design build process. This project deserves the DBIA WPR award as our collaborative approach delivered the vision the Owner wanted captured in their new HealthCare facility. The new Sharp-Rees Stealy Downtown Medical Center is the culmination of years of dreams and hard work by a large inter-department team, which comprised of Physicians, staff, patient feedback, and augmented by our designbuild team that brought this vision to reality. All this effort resulted in a facility that has been measured by Pressganey for Patient Satisfaction scores. Patient scores soared from 3.55 in 2012 (49th percentile) to 4.86 in 2013 (83rd percentile) and Physician satisfaction scores increased from 4.34 prior to new facility to 4.59 after operation. We created a beautiful new environment to match the quality of care provided by the Sharp Rees- Stealy Wellness Group, who are up for a Center of Recognized Excellence (CORE) award for their new HealthCare facility.
he Sharp Rees-Stealy Medical Center project is located in the historic Banker’s Hill area in downtown San Diego. The construction of a new healthcare facility consisted of approximately 68,000sf of new medical office space and a 300-stall, 4-story parking garage with a lower level basement under the footprint of the building. The overall site development is approximately 1.39 acres, or on approximately 60,330sf, and required over 32,000 yards of exported dirt to established specified grades. The Medical Office includes a new Pharmacy, Physical Therapy, Nutrition, Business Services, Optical Shop, Patient Education, Ophthalmology, Allergy/Immunology, Clinical Research, Radiology, Occupational Medicine, Urgent Care, Specialty, Family Medicine and Internal Medicine depsrtment. The project was completed in 19 months with a substantial completion date of Novemeber 13, 2012. The Owner’s goal was to provide the highest value, which they defined as maximum benefit over minimum costs. Their objective was to have patients leave with the impression that their healthcare dollars are being used wisely on healthcare and not buildings; therefore, the major challenge was to create the Medical Center with an impression of quality, professionalism, cleanliness and modernity with the designated space requirements allocated with the proposed site. The Rudolph and Sletten/AVRP Studios’ goal was to design and deliver a building that was timeless ,state-of-theart, inviting, friendly, uniquely fit its urban neighborhood and met the overall experience the Owner desired for their patients and members. To achieve this we focused on a 3-story grand atrium lobby to serve as an orientation point and allow ample amount of natural lighting into the facility, creating a “living room experience” to reduce patient anxiety and inspire a sense of comfort. Our design creates a crystal-clear circulation with patient/caregiver zones with private entrances for physicians, thus supporting the Owner’s mission to improve the health of the community
through a caring partnership of patients, doctors, and employees. Each zone is designed to increase access to natural light, reduce unnecessary stress with comfortable furnishings, orientation cues and efficient function and operational movement. In focusing on the Owner’s mission, we were able to exceed their design expectations. Our challenges and constraints involved the proposed lot (200’x300’), zoned within a Mid-town/Uptown planning area with a historic fig tree that was to remain, achieving the Owner’s functional space program requirements and the site located on Lindbergh Field Airport’s AAOZ (Airport Approach Overlay Zone) with a zoning height limit at 40 feet. To meet and exceed the challenges during the Request for Proposal and proposed design stage, the team met multiple times with the City of San Diego to ensure our design met all guidelines necessary to receive Process 1 Status and avoid delays by bypassing a lengthy discretionary hearing process. Additionally, our design submission obtained prior approval from the Federal Aviation Administration’s zoning requirements. We conducted over a dozen alternative site studies which allowed our design to meet the City and neighborhood demands to fit its urban context, while also meeting the Owner’s project goals. These challenges carried over during construction. Building around and protecting the 110 year old historic tree while excavating 30 feet below street level for the basement required special shoring design and the upmost care to keep the tree healthy. Same time working overhead under the San Diego Lindbergh Field Airport necessitated daily communication with air traffic control tower with workaround and shut downs during adverse weather conditions. A LEED Gold Certified project exceeded Owner’s expectations, achieving a 100% of the desired program, of which 95.5% was called for, provided more parking spaces than requested and delivered 6 months earlier than the Owner required.
Facilities Management & Development
Owner Letter RE: Recommendation for the Rudolph & Sletten Design Build Team For the Sharp Rees-‐Stealy Wellness Center, San Diego Dear Design Build Awards Jury, Two great architects at the turn of the century, set forth two powerful goals that still define great architecture. Frank Lloyd Wright called for form to follow function; and Le Charles Corbusier taught us to capture the light and make it enhance the experience of the space. The Sharp Rees-‐Stealy Wellness Center accomplishes these two design goals and the result is a great medical office building. Physicians, staff, patients and their families step into the building, stop, admire the environment and say “Wow”! The project was successfully delivered on schedule and under Budget. Between the outstanding design from AVRP Studios, and the skillful construction by Rudolph & Sletten, we delivered a Design-‐Build project that truly exceeds expectations. Under today’s healthcare reform, reimbursements are directly tied to Patient and Physician satisfaction scores. Now a building must prove its performance through feedback scores. The building opened for service in November 2012 and the results are: -‐ Patient satisfaction scores soared from 3.55 in 2012 (49th percentile) to 4.86 in 2013 (83rd percentile), -‐ The overall physician satisfaction score increased from 4.34 (before the move) to 4.59 (after the move), and -‐ 50 of the 62 physicians have donated $5,000 or more to the construction fund. The Sharp Rees-‐Stealy Wellness Center is a great project, built by a great Design Build Team! This $37M project continues Sharp’s 90 year history of healthcare service to downtown San Diego. I strongly recommend the project for a DBIA Design of Excellence Award. Sincerely,
Pat Nemeth, VP Facilities Management & Development
If I had to diagnose the downtown reaction opening day, it would probably be a collective case of mild to moderate shock – everyone that has e-mailed me uses words like ‘speechless’ ‘ecstatic’ and ‘awesome.’” Anne Bachan Jigger VP of Philanthropy, Sharp Healthcare Foundation
Evaluation Factors The Best Value Bid process was used, with 70 points for the Technical Submittal and 30 points for the Interview. The Technical Submittal evaluated the proposal based on: Interior Design and Program Compliance, Exterior Design, Schedule Work Plan and Construction Logistics. Technical Submittals were evaluated “blind” by a jury of Sharp design professionals and clinical staff. The Interview panel was comprised of SRS Physicians and Sharp SRS executives. Method Used in RFQ & RFP The RFQ briefly described the program for the project. Companies were scored on: Comparable Project Experience, Design Build Experience, History of Claims and/or Litigation, and Work in the San Diego market. The RFP used “performance requirements” with pre-schematic bridging documents to define the program, adjacencies and site development requirements. In addition certain “prescriptive Sharp requirements” were also included. Design Build Contract Format The contract form is a Sharp modified DBIA contract. The Sharp modifications were minor.
Basis of Contract The basis is a lump sum contract. In addition, the contract included a number “Add Alternates”, which were good for a certain period of time. Risk Assumption & Risk Allocation Sharp required the Design Build Team to be responsible for code compliance. Sharp assumes the responsibility for unforeseen conditions. In addition, the risk for delays in permitting was shared 50/50. All Owner Changes were documented through Bulletins, approved in advance and compensated by the Owner. Awards & Incentives There were no formal awards or incentives. Three Challenges Associated with the Project 1. Hazardous Waste Clean-up of Burnt Ash 2. Value Engineering for ~ $900K 3. Revised Electrical Distribution Due to Equipment Changes
o exceed the Owner’s schedule expectations, our design build team’s approach was to have the design and the construction to be a single, integrated process, with significant and consistent team participation throughout the process. Our schedule and work plan was addressed in three major phases: preconstruction phase, the permitting and entitlement phase and the construction phase. Within these major phases, each will have its own milestone that the design build team must meet in order to maintain an even flow of the schedule and in order to guarantee that the project will be completed on time and on budget. The tools utilized in this process are Integrated Project Delivery (IPD), Pull Planning, and LEAN Principles.
illustrates that a collaborative alliance of people, systems, and practices into a process that harnesses the talents and insights of all participants to optimize project results to increase value to the Owner, reduce waste, and maximize efficiency does work and is successful.
We had schedule changes as a result of unforeseen conditions in the soil and accommodating new selected Owner furnished equipment. During excavation burnt ash and California Hazardous Soil was discovered and resulted in approximately 7,000 cubic yards of the 32,000 cubic yards required to be exported. Prior to MEP rough in, Owner selected equipment and functional requirements were changed that required a redesign to accommodate new branch circuitry electrical loads.
In completing our functional space design having Owner’s participation in the beginning to understand the needs of each department head was critical. This close involvement allowed us to finalize project documents with cost changes evaluated at that time and prior to permitting and construction. This strategy continued during buyout in working with subcontractor to maximize design intent with the most cost effective systems, material and resources available. The result is obtaining more “bang for the buck” and exceeding the expectations established at the RFQ/RFP phase.
In both situations through our partnership with the Owner, our team utilized IPD and pull planning to reduce the overall cost and schedule impact. We worked as a team to expedite the San Diego County approval process for the hazardous soil and the City of San Diego on redesign approval while collaboratively agreeing to cost and schedule changes. With pull planning we were then able to re-sequence work activities and work flow to greatly reduce the overall impact of both situations. This further
By forming this partnership with IPD the design build team was also able to save time and money to enhance the project value to the Owner’s benefit. Our team utilized Building Information Management (BIM), Revit, Tekla, and Value Engineering (VE) from the RFQ/RFP through post award phases of design, during construction and will be used into commissioning.
With the software utilized, we were also able to evaluate how to build the structure and systems more effectively and identify constructability items. This establishes a clear workflow from the beginning and allows us in return to have a very efficient building that reduces the commissioning time associated.
design & quality approach
s with many design-build projects, the design criteria of Sharp Rees-Stealy Medical Center presented its own set of programmatic challenges along with a series of external constraints that needed to be coalesced into a state-of-the-art medical office building camouflaged in historical motifs to match its neighborhood. It was through open collaboration of the designbuild team that such a successful result could be accomplished. Siting the building in a downtown neighborhood brought on a series of external constraints. First, the building had to meet the requirements of the external agencies that had influence on the block which is clearly illustrated in the “Agency Compliance” graphic. Also constraining the footprint was the desire to maintain a 133 year old historic Morton Bay Fig tree. To further visual impact, the building needed to keep consistent with the neighborhood, so the design needed to reflect a modern interpretation on the Mission Style architecture of Balboa Park in San Diego. All of these constraints bounded an ever expanding and complex program. The final program consisted of approximately 65,000 sq. ft. of medical office building containing specialty medicines, radiology, urgent care, pharmacy, medical laboratory, ophthalmology and a separate parking garage for staff and patients to minimize
impact to parking. Due to this complexity, the design of the building was continually refined between the design team trying to maintain the requirements for the program and the construction team trying to keep the price of construction manageable. This refinement happened both before and after the bid was awarded. During the initial phase, the team focused on the overall vision and production of a viable potential building design, an end product that Sharp needed to move into the 22nd century. Once the project was awarded, the design team focused on major design issues and analyzed how they could be designed to control their cost. For instance, the glass tree wall was originally conceived to fill every pane on the wall. After receiving bids for creation and installation of the concept, the image was parsed, selecting specific panels of the super graphic, thus lowering the price while still maintaining the original concept. A second example of the designbuild collaborating for the betterment of the project is the final outcome of the courtyard. Having not been fully designed in the initial submittal, the interior courtyard needed to finish being designed and have a real cost associated with it. The design-build team created a series of charrettes with associated pricing and presented them to the client to choose their preference within the allowance for the courtyard feature.
This practice became regular throughout the project, giving the client significant influence into the building design and after awarding the project without compromising the budget set forth by the initial bid. With the demand for this building to be Sharp Rees-Stealy’s flagship medical office building, it was imperative to continually check quality of the design and construction. To verify the quality of work, the team focused on open and multi-avenue communication. The contractor continually reference three-dimensional renderings and computer models to better understand the design intent and how they were going to achieve it. When a computer model was not enough, the design-build team built a mock-up and regularly reviewed it with the client, making continual changes to perfect every last detail. Every person on the job was included in this level of detail. Each sub-contractor on the project was briefed on the design intent of the project so they could understand the desired outcome, quality of the project and realize that every decision affects the whole design-build team instead of just a single trade. All of these quality assurance measures helped guarantee that such a complex project would exceed the expectation of the client, creating a building that, as one patient put it, “couldn’t be the place where [you] see [your] doctor.”
he design-build team focused on constant collaboration between architect and contractor to design and build a state-of-the-art medical office building. Through the design-build relationship, the team was able to utilize innovative systems and methods to improve the design, life-cycle costs, and overall final building. The Sharp Rees-Stealy Medical Center is the first LEED certified medical office building in Sharp Heathcare system, achieving the level of LEED Gold. It has further been recognized by San Diego Gas and Electric as a case study for their Savings By Design award. Both of these prestigious accolades would not have been possible to achieve without the entire Design-Build team working together. Each team had to be involved from the onset of the project and continually kept abreast of multidisciplinary decisions so the project could maintain its rigorous sustainability goals. It was due to this teamwork that design features like the green roof and the electric car charging stations were added. Part of the clear communication between teams was due to the extensive use of new technology and BIM strategies. The
architect and design teams used Revit as their primary design documentation program. This allowed the contractor to add 4D BIM into their work flow, allowing them to review clash detection, scheduling, and energy modeling before construction. A clear example of the value added by 4D is that the sequencing of the excavation was changed because a more efficient critical path could be established due to having the building sequence modeled. This saved time and money for the design-build team, which was then passed onto the client. Part of the 4D BIM exercise was relating specified product to its overall life-cycle cost. Again, the design-build team intimately worked together to achieve a better design at a lower cost by reviewing the entire building and suggesting improvements based on their expertise that would affect the overall building. Multiple materials were substituted for comparable product at a lower price point. Much of the original stone was replaced with GFRC while the original GFRC was replaced with foam. This kind of value engineering lowered the cost of the project while maintaining the overall design.
As the design was refined, real prices could be associated various design features. Rather than removing these features, many of which were the reason Sharp chose the design, the team worked together to come up with a strategy to reduce the cost of the feature without compromising the overall design. Initially intended to have graphics on every window of the glass tree wall, the wall was refined to maintain budget for that feature. The luxury vinyl tile plank and porcelain tile flooring were both specified because the design team was able to communicate the design aesthetic to the contractor and the contractor was able to express concern for life-cycle cost and true functionality of the various floor material alternatives to the designer. This kind of collaboration allowed the design-build team on multiple occasions to make universally best-case decisions for the project. The team even came up with an alternate material not used in the construction industry to reduce the cost of the green screen wrapping the parking structure. This kind of innovative material selection is best realized in a designbuild atmosphere because the each team is focused together on an end goal rather than their individual motives, removing the silo effect in the construction team.
e feel safety is everyone’s responsibility. To prevent incidents and injuries and to meet and exceed our strategic safety initiatives we feel is a team effort requiring communication, foresight, vigilance and dedication. We have a full time Jobsite Safety Coordinator that puts every employee a Subcontractor Injury Prevention (SIP) program that address job specific items and explains our core beliefs as follows: •
Communication is the exchange of information between people, by means of speaking, writing, or using a common system of signs or behavior. As a worker onsite when you are made aware of any unsafe acts, unsafe conditions, it is your duty to immediately communicate these concerns to a Supervisor or Jobsite Safety Coordinator. Foresight is the ability to envision possible future problems or obstacles. We feel if you plan ahead hourly, daily, weekly and monthly to have solutions to any possible future problems or obstacles we may encounter. These solutions could include hazard elimination, specialized training and procurement of special equipment and materials. Vigilance is the condition of being watchful and alert, especially to danger. All employee must pay attention to their surroundings for changing conditions, keeping in mind on the task at hand, and to not let personal issues because a distraction. By watching out for the safety of fellow employees and knowing/understanding our safety policies, Fed/OSHA and Cal/OSHA regulations and any other site specific requirements. Dedication is being wholeheartedly devoted or committed to a goal, cause or job. We are dedicated to providing the safest working conditions possible and to prevent injuries from ever occurring on any of our projects or in our offices. This is a goal that requires the combined efforts and commitment of all involved. By working together it is possible to be safe and productive at work and be able to go home intact and enjoy the company of our family and friends.
For this project we developed a site specific safety and health policy manual that gets explained to each worker during the SIP process. We further hit these items every Monday at 7:00 AM at an “all hands” safety meeting, an agenda is attached. Due to job specific requirements we required Hazardous Operators certification during contaminated soil removal, performed specialized Forklift Training and required employees to have a Respiratory “Fit Test” for their specific scope of work. As overall involvement is critical for implementing a successful safety policy and procedures we provide safety incentives to all workers. These safety incentives include, but not limited to, safety raffles for small tools, free t-shirts, free hats and we also throw safety milestone barbecues to employees for the commitment to having a safe working environment. Utilizing these skills we will continue to be “The Best and The Safest” and will meet and exceed our strategic safety incentives.
TOTAL HOURS WORKED ON PROJECT
DURATION OF CONSTRUCTION (IN MONTHS)
CASES WITH DAYS AWAY FROM WORK
CASES WITH JOB TRANSFER OR RESTRICTION
OTHER RECORDABLE CASES
* 398 days on the job without any recordable incidents
mock•up exam room
real exam room
harp is an integrated healthcare system, with two affiliated medical groups. One of those medical groups is Sharp ReesStealy (SRS). Dating back to 1928, the original Rees-Stealy Medical Group is the oldest primary care and specialty care physician organization in San Diego County. Today SRS serves the County with over 400 physicians, located in 22 medical office buildings. The SRS Downtown Medical Center was a project dreamed about for years by the physicians who worked in the old original flagship building. More than one doctor said they were told there would be a new building when they hired on some twenty to twenty-five years earlier. Thus the original vision for the building was simple: • • •
Continue to provide healthcare service in this location Solve every functional problem experienced in the old building Embrace technology advances in both healthcare delivery and building design
The vision was translated into five major healthcare performance goals for the design of the building: • • • • •
Integrate the electronic medical record into the design of the exam rooms Improve infection control by hard-wiring hand washing with the placement of sinks in all care giver areas Make way-finding easy for patients and their families Decrease Urgent Care service delivery times by improving the adjacencies of services such as radiology and lab Locate pedestrian activities on the ground floor to reinforce the urban community experience, i.e. ophthalmology, the optical shop, the pharmacy and physical therapy
All performance goals were accomplished by the project. Two other key Design Goals were also accomplished: • •
The preservation of a State designated historic Morton Bay Fig tree, planted by Kate Sessions The building is designed to achieve LEED Gold and is be 29% % more energy efficient than required by the California Building Code
Finally, the Owner’s vision was to create a new flagship home for SRS that would exceed staff and physician expectations. The Rudolph & Sletten and AVRP Studios building is a legacy building; it will serve the public for decades to come. To meet the rigorous requirements set forth by the owner, the team needed to have constant communication with each other and with Sharp Rees-Stealy facility staff. The design-build team used digital models for documentation, rendering, and animation. These exhibits were regularly presented in meetings with the full team gathered. To further clarify the major building block of the medical office building, the exam room, the team built a full size mock-up which to make sure that every person, from owner to sub-contractor, had the same understand of how the exam room would be built. As plans and ideas changed, the mock-up would be updated to keep it as an accurate example of what the finished product would look like.
Letter from the designer
s with many projects, each site and set of circumstances presents its own set of challenges. This project is different that the medical campus or suburban medical center because it is situated on an urban site bounded by residential & small businesses, airplane glide path/approach, a sloping urban lot, a historical tree and on-site parking and confined to a small budget. This unique site required a significant amount of collaboration from the entire design-build team, whom successfully designed and built an exceptional building with the given set of constraints. The team worked together during the initial selection phase to locate major design details and give initial costs for construction. As the design was further realized, new and alternative methods were researched to maintain the aesthetic without over running the budget. The interior courtyard design is an excellent example of how the team worked together initially to conceive the idea of having a courtyard within the site, but had to refine the design after the contract for the project was signed. During refinement, the design-build team approached the owner with various options for the courtyard that were with the budget. This style of customization allowed the client to continue to influence the projectâ€™s final design without compromising the budget to build the project. Designing Sharp Healthcareâ€™s first LEED certified medical office building needed very open and responsive collaboration between all design disciplines and contractors. To achieve a LEED Gold rating for a building with an already complex program required each team member to continually analyze all changes to the design that would affect program or the buildings sustainable impact. When reviewing the green roof, for instance, the decision was eventually made to keep it because both the mechanical systems designer and LEED specialist showed the negative impact of removing the feature. Assessments like this by each team member need to be returned to the entire team quickly or the team would run the risk of losing too many opportunities for sustainable design and construction, therefore potentially not being able to receive the LEED accreditation. The Sharp Rees-Stealy Medical Center is a strong example of what is possible with constant collaboration among all team members of a design build team when faced with a series of complex challenges.