- Explain the circumstances that led to needing a new facility.
Greg Gore: Most of the old hospital was anywhere from 30-60 years old, had outlived its useful life and didn’t have the infrastructure needed to keep up with advancing technologies. Though its location in the heart of Murfreesboro was a good thing when it was originally built, over time it became landlocked and wasn’t easily accessible for the expanding community.
Rutherford County is one of the top five fastest growing counties in the United States, but its growth is extending primarily north and west of downtown Murfreesboro. Before the new hospital, people would either go south to Chattanooga or northwest to Nashville for care. Strategically, the hospital needed to move to capture that market share, and they needed to be close to the interstate for easier access.
- Perception and public interest in this project were extremely important. What measures were taken by GS&P and MTMC to keep the public engaged?
Greg: Promises to the community about a replacement facility had been going on for years. The staff, physicians and public had grown skeptical if the replacement facility would even be built. In an effort to illustrate the project would quickly become a reality, remediation of the site began prior to the design of the campus. Site work alone was not enough, however, and MTMC contracted us to design the DePaul Medical Office Building on the site prior to building the hospital. The fast track of the DePaul MOB improved the confidence that the replacement facility would finally be built.
- How common is it to build an MOB before building the hospital?
Greg: The MTMC master plan of the hospital was completed after the DePaul MOB building was designed. That’s backwards from how it is usually completed. Typically the hospital is designed first and the MOB is located and designed relative to the hospital.
- How big of a challenge was it to work in this sequence?
Greg: Really big. The challenges imposed on the design team were to locate the MOB in such a manner that it would not impede the location or access to the yet-to-be-designed hospital. We also had to design and detail the DePaul MOB with materials and features that would not constrain our freedom to develop the aesthetics of the hospital. In essence, the design team had to design the entire campus and associated building completely backwards from the traditional process in which the MOB takes design direction from the main hospital.
The DePaul Building was occupied 18 months prior to the completion of the hospital, and patient care was delivered on the campus with the backdrop of the 550,000-square-foot construction of the new MTMC.
- Once MTMC was completed, how did you support the staff?
Greg: Since many of the staff had been doing their jobs the same way in the same circulation patterns for 20 years, it wasn’t easy for them to embrace a new way of doing things. We had countless sessions with all the staff to ensure that their ideas on standardization were met. We built mockups that mimicked the design of each room and allowed us to move things around easily to come up with the best configurations. We progressed all the way through to a 100% finished mockup that had the floor finishes, the ceiling, the paint colors, and even the devices that would be used. We walked the staff through the mock patient rooms so they could understand the layout before they even moved.
- Since the hospital could not pause its operations, how did the staff and departments transition over?
Greg: We used a transition planning service and began moving the entire building at 5:30 a.m. on October 2, starting with existing patients in the ICU, then oncology, then orthopedics. In most cases, ER patients went to the old hospital, but one woman came to the new hospital ER at 4:30 a.m. in labor and refused to go to the existing hospital. They made an exception and admitted her at 5:15 because they didn’t want her to have her baby in the parking lot.
- Overall, did the transition run smoothly?
Greg: Yes. The transition was really uneventful, and it is a testament to great team planning. In fact, the CEO said he kept waiting for something to happen, but it was so well planned that it ran without a hitch. There was a convoy of ambulances that ran from one hospital to another. They expected it to take all day to move, but they were able to move about 100 patients from the old facility and admit them to the new hospital in about four hours.
- The development of the new hospital was driven by the Integrated Project Delivery method (IPD). How does this method differ from standard procedures and what are the advantages of using this process?
Greg: In most hospital developments the owner typically has a contract with the architect and a separate contract with the contractor, which, unfortunately, can produce adversarial relationships if something goes wrong. Each entity tends to think about their own interests and how to shift blame or responsibility.
With IPD, the owner, architect, and contractor enter into a single agreement which contractually binds each to the other to essentially create a three-legged stool. With this process, everyone puts the project first. If someone needs help, the other two jump in to support instead of pointing the finger or deflecting. This team attitude permeates the entire project and makes everything run much smoother.
This was an enlightening process for us. Decisions made were not just based on design aesthetics, but with input regarding constructability, financial implications, and longevity.
- What other process did IPD support?
Greg: The IPD team extended to sub- contractors as well. The subs were involved with design assist in which solutions were coordinated across disciplines prior to final documents. One example of design assist is the effort to develop a method of setting the windows prior to the installation of the masonry. The end result was the ability to weather-tight the building months ahead of the original schedule.
- How did IPD reduce Requests for Information (RFIs)?
Greg: Issuing RFIs is a standard process that the contractor uses to ask for clarification on the construction drawings, and it usually leads to a change order if there is a conflict on the documents or if information is missing. The Building Information Modeling (BIM) models developed by GS&P and the mechanical, electrical and plumbing engineering subs on site allowed for a tremendous reduction in RFIs as well as better coordination of installed systems.
A project of this size delivered in the traditional method probably sees more than 1,000 RFIs, which adds tremendous cost and time to the process. The MTMC project had around 100 RFIs that were “real” and an additional 300 that were “confirming,” for a total of around 400—an unbelievably low number.
- How much of the success of this new facility do you attribute to Integrated Project Delivery?
Greg: We were well ahead of schedule and more than $3 million under budget, all while the markets were crashing in 2007 and 2008. I attribute that success to the IPD process and the fact that the team was incentivized. In a standard agreement, the owner and the contractor usually split savings. For the first time in this company’s history, the designers were able to participate in the profit-sharing which created a great incentive that paved the way for a successful project.
- Circulation and wayfinding were confusing in the old building. What concepts were implemented to create an improved sense of orientation?
Greg: We spent a lot of time studying circulation patterns in the old facility. Our goal with the new facility was to not have any back-of-house functions in the view of the public. Instead, every space that the public or a patient needs to get to is immediately accessible. The chapel, administrative offices, outpatient diagnostics, imaging, emergency, same-day surgery and waiting rooms are all now off the main lobby. Visitors can access every area, including treatment rooms and diagnostic testing, directly from the lobby without seeing administrative areas.
We also moved the emergency department (ED) to the front of the facility, something I’ve never done before.
- How did relocating the emergency department improve wayfinding?
Greg: Typically, EDs are located on the back of the hospital, and because hospitals lock main entrances at night visitors must enter through the ED. This creates new circulation patterns, flows and even security issues. By bringing the ED to the front and adjacent to the main lobby, visitors can safely park near the main entrance and walk around the corner to enter through the ED. It eliminates the poor visitor experience of having to come to the back door just to get to the front door.
- Another priority of the new design was to enhance patient safety through standardization. How was this supported?
Greg: In a hospital setting, standardization plays an important role in reducing the chances of medical errors. A great example of this is that every patient room at MTMC is standardized, or same-handed, allowing caregivers to always approach patients on the right-hand side of the bed. In a typical back-to-back room configuration half of the rooms approach the patient’s right side of the bed while the other half goes to the patient’s left-hand side. With the new facility, everything is identical, even in the nursing units, so that staff can easily move from floor to floor or room to room without having to reorient themselves.
We also incorporated distinct zones in each patient room to address the needs of the family, the patient and the caregiver, each with considerations to help maximize the healing experience. Designing an outboard toilet, for instance, removed a potential obstacle for caregivers as they enter the room. Placing the entrance of the toilet close to the patient’s bed reduced the space needed to travel. Adding handrails to the path from bed to toilet helps mitigate patient falls. Placing the family zone far from a room’s entrance keeps loved ones out of the path of caregivers, but also reduces interruptions in the middle of the night. All of these details help to remove potential barriers to care, or latent conditions, and improve the environment’s ability to impact the healing process.
- Explain the design team’s inspiration for the lobby.
Greg: Entering a medical facility can be a daunting experience. We wanted to soothe that anxiety through the design of the lobby. It’s not just a point of entry or transition; it’s a dynamic two-story space flooded with natural light, a gathering place where people can rest or congregate. The design uses dynamic curves to pull visitors in from the front door. The overall shape of the space makes you want to go all the way through to see what’s on the other side. Instead of just seeing everything at-a-glance, visitors follow the curves of the building to experience everything.
Ashley Roller: The main lobby is unique in that it follows the healing garden which in turn is wrapped around the chapel. Every step up to and inside the entrance is a surprise. Because of the curves, you don’t fully see everything at once, more becomes revealed to you as you move through it. The curved façade shelters the healing garden creating a very private serene area, which is unexpected from the front door.
- What interior design elements were used to create a serene environment?
Ashley: We drew a lot of inspiration from the landscape and scenery around Murfreesboro to design a continuous finish palette that was used throughout the building. We used a very unique stone that mimics the natural elements of the nearby Stones River to create an uninterrupted sense of peace and tranquility as visitors navigate from the waiting area to the elevator lobby and into the chapel.
We also drew inspiration from working with the chaplain at MTMC to incorporate a vision of their faith into our design. Warm inviting colors, wood, stone and porcelain were carried throughout. We also created quaint, intimate seating areas and small cozy alcoves to provide visitors with private places of respite during their visit. We avoided anything too overpowering so that each space is warm and inviting.
- What design concepts were used in transition areas?
Ashley: We wanted to eliminate any sense of hierarchy between departments or patient units, while keeping visitors oriented. Stone was used at each elevator bank on all seven floors and in every waiting area to create a constant reminder that this is the exit to and from each floor. We also used glass screen walls as a continuous theme in the nursing units. The patient floors are curved, each with custom wall coverings imprinted with graphic images of Murfreesboro taken by local photographers, which aid wayfinding and orientation.
- As the anchor, how has the completion of MTMC positively affected the Gateway Design District?
Greg: MTMC has the responsibility of driving further development within the district, and you can see evidence of the successful impact in the new medical office buildings both on campus and adjacent to the site and the surrounding medical clinics that have been constructed. Retail and hotel projects continue to be built adjacent to the campus as well. All of this is possible due to acceptance by the community, staff and patients.
- What does this new facility mean for Murfreesboro and its citizens?
Greg: It was a huge accomplishment to build a new state-of-the-art facility that would prevent patients from choosing other locations, miles from home, for their healthcare. Even with the same number of physicians and staff, the patient census has far exceeded the client’s expectations. The community has clearly committed to the new MTMC. The campus is alive with activity and it is truly a destination for healthcare in Murfreesboro. In fact, the MTMC chief of staff, Dr. Andrew Brown, has taken time to walk visitors around the new hospital because he was so impressed. A local woman was quoted in an article saying, “I cannot believe they built a facility of this magnitude and quality in little Murfreesboro, Tennessee.” That really sums up the whole project and the positive impact it will continue to have on the community.