P
rinceton HealthCare System (PHCS) has a new 238 bed, 575,000SF non-profit Acute Care
Hospital, University Medical Center of Princeton at Plainsboro (UMCPP) consisting of a patient
bed tower, a diagnostic and treatment building, an administration and education building,
and an on-site co-generation plant that supports the hospital.
What was your vision for this project?
In undertaking this project, we were determined to build one of the finest hospitals in the United States. A hospital
that would support and encourage outstanding clinical care, provide the most advanced technology,
and demonstrate commitment to our community by incorporating sustainable design and function.
C a n y ou descri be the p rocess that l ed to Pr i nceton Hea l thC a r e Sy s tem unde r t a k i n g
t hi s pr oject ?
Going back to the very beginning, we embarked on a strategic planning process
back in 2003.
It was our first comprehensive strategic plan, and it was driven by the
fact that we knew that we needed to replace our 93-year-old acute care hospital.
Our vision developed as we got into the planning process and realized that our
hospital
campus was “landlocked” in a mature, residential neighborhood in Princeton. There was
simply not enough space to expand in order to meet growing demand. We wanted to find a
way that we could expand our footprint in our service area to meet those growing needs.
The
original
site
could
not
accommodate
the
technology and clinical practices; it was also not
the changing demographics of the growing and
latest
developments
able to expand in
aging population in
in
medical
response to
our region.
After a long, highly participatory and transparent process, we realized that our best option was to
relocate from our original site of nine acres, which would have led to an inevitable land crunch 40 or 50
years from now, to a larger site with greater opportunities for development.
We were able to find a new parcel of land, with 171 acres, that was located only three miles away. It
allowed us to explore all kinds of options to support our community healthcare needs. The location that
we chose placed us in the heart of 70% of our traditional patient population, making us very accessible.
It was a substantial commitment to that vision when we bought the land. We knew that we
wanted to create something special on the land we purchased. It allowed us to do more
than just replace the existing hospital; it allowed us to use this one-time opportunity to develop
a unique health care campus with mobility and access for our community.
By reaching
across their entire spectrum of health needs, we could provide a genuinely holistic healthcare
environment. To do that, we envisioned a campus with our acute care hospital and much more:
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Skilled nursing and sub -acute care
Fitness and wellness center
Assisted living
Age restricted independent living
Pediatric ambulatory care facility
Child day care
Adult day care
Medical office building
Co-generation facility
You talk about your vision for the project; what were the key points that you focused your design
team’s attention on?
We started with guiding principles that helped us make design decisions throughout the process. We
wanted the building itself to help:
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Reduce infection
Reduce errors
Reduce falls
Improve patient and family satisfaction
Decrease operating costs
Improve clinical outcomes
Reduce carbon emissions and use of
harmful chemicals
• Improve financial performance
We kept our sight on those guiding principles and every major decision that we made on the project,
from start to finish, was based on “What is the best solution, based on those key items”?
Do you feel that those goals were met?
We have achieved all our guiding principal goals. In fact, we have exceeded our expectations!
As of this past May, we have now occupied the medical center one year, so we took some time to look
back and see how the hospital performed against our expectations. Given the nature of what we do as
healthcare providers, there are lots of surveys, rankings and tracking tools that we monitor to see where
we are in terms of our guiding principles.
If you look at the statistics after this first year of operations, we have a lot of data to be proud of:
• Overall patient satisfaction ranking in Press Ganey is in the 99th percentile compared to all hospitals
in NJ
• Patient satisfaction with physicians is 99% for all hospitals in NJ
• More physicians joined our staff in the past year than at any time in our 94 year history.
• Inpatient volume is up 7% since we opened, in a state where the average is down 2%.
• There has been an18% increase in emergency department volume since we opened our doors.
• The Leapfrog Group gave us an “A” for patient safety and clinical quality of care score, based on
preventable medical errors and hospital-acquired infection rates.
• The state of New Jersey asked us to teach other hospitals how to reduce bedsores, due to the fact
that we had no bedsores at all in our hospital this past year.
• We have the lowest re-admission rate in NJ
• The Becker’s Hospital Review ranks our hospital as one of 100 Great Hospitals in the U.S.
We had a big vision and some ambitious guiding principles. It was “go big or go home” all the way.
It is really gratifying to see how close we came to the mark, based on these objective measurements.
Talk us through the process, and how you came to many of the major decisions involved.
This was an enormous undertaking. It takes so long and there is so much risk associated with it, that it
requires enormous care during the planning stages. There is a lot that needs to be lined up from the
outset. We needed to dig into the financial planning, and we worked hard on getting public support.
It was also necessary to line up the government backing that’s required in terms of the needs permits
and the land use process.
We also deliberately aligned our structure for the long haul. For example, we reorganized our Board
of Directors at the outset of this project to make it more diverse, to be sure that it represented the
community that we serve. That is important for building trust. We created an independent project
oversight committee, and we separated the auditing function from the finance committee. We also
brought on trustees with experience in public finance, law, auditing and construction.
A project on this scale incurs a huge risk, with an unbelievable amount of money coming into and out of
the organization in a very short amount of time; it requires more care than many people may realize. It
is crucial to put systems into place at the outset, and to make sure that you are overseeing that process
very closely.
We also recognized that hospital executive tenure averages about four years. Measure that against
the process of designing and building a hospital on this scale. Our project took nine years. That means
that succession planning is essential. We had every executive create a detailed succession plan; we
ended up with almost half of them being implemented due to turnover. It was essential to our process
and had a major impact on our momentum, because in the middle of making an important decision,
those key decision-maker replacements had to step in and respond.
Can you tell us a little bit about your process to research and identify hospital best practices that
you wanted to embrace for your project?
We invested a lot of time and attention in getting this right. We undertook a formal review of 12 new
hospital projects across the country.
As part of our preparation process, we became active members of the Center for Health Design, which
supports research in hospital design. We reviewed all available research and decided which were
most meaningful for our project and we included those factors in our design. For example, research
suggested that:
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There is a higher occurrence of treatment error when patient rooms are different.
Natural light has a positive impact on patent outcomes.
Art reduces the impact of stress on patients and visitors.
The use of 100% outside air reduces hospital-acquired infections.
Frankly, the amount of research in facility design is incomplete. We simply did the very best that we
could, based on stakeholder input, but not all design decisions are supported by research.
We also got involved with the Pebble Project®, which is a collaborative of healthcare systems that are
involved with the Center for Health Design, designers and industry partners working together on design
solutions that improve patient and staff safety, clinical outcomes, environmental performance and
operating efficiency. Through the Pebble Project, we identified the importance of the hospitality factor
in our hospital. Again, it goes to first impressions. From the hotel industry, research indicates that people
form their first impression within the first 50 feet as they enter a building. That’s about 50 seconds to
form a favorable or unfavorable impression. And that impression can influence our perception of every
transaction that happens in the building.
At the end of the day, patient safety is our number
one issue. Since we opened our doors one year ago,
we have had floods, hurricanes, an earthquake,
sustained temperatures over 100° F degrees, a
tropical storm and a regional power outage … we
called it “shake, bake, blown and drowned”, and
the hospital operated well under all of those extreme
conditions. We also learned some lessons about how
we can operate even more effectively when a crisis
occurs in the future.
And the decision-making? How did you come to
your decision-making process?
We knew that every decision had an important impact on the final hospital. Whether the item being
considered reduced stress, increased staff efficiency, improved clinical outcomes for patients, or
supported families; we thought about all of these factors when making a decision. So that meant
that we had to weigh each of these factors differently as they impacted safety, infections, falls, staff
convenience, and productivity; they are all important and they all have to be addressed by the design.
But the next sets of priorities might be based on the hospital’s attractiveness as a marketing tool, or the
ability to attract and retain a professional staff of the caliber that we wanted for our community. All of
the decisions were weighted by priority and those were our ultimate decision parameters.
Can you go into a little more detail about your collaborative design team approach? What were
some of your successes, what were your challenges?
One of our influences was the fact that 3% of the cost of a building goes into the planning phase. We
knew that we would spend the remaining 97% of the project cost over the lifetime of our project and
that cost is profoundly impacted by the original 3% planning phase investment being made wisely.
The design process took three years to complete and it was continually evolving over that period. In
the very first phases of a project, you are making decisions that will impact the entire process. Every
change that you make during the construction phase is so expensive that you sometimes don’t make
the changes that you would like to because of the increased cost associated with doing it during this
phase of the process. That makes it really important to take the time to do it right initially. This means
being thorough, engaging the professionals early enough, and working with the right professionals to
make informed decisions.
I would recommend bringing engineers on at the same time as the architects and the construction
managers. With all three disciplines on board with the project from day one, you can make some very
smart decisions.
We knew that we could do the energy modeling and planning that would return energy cost reduction
of 25% and reduce our carbon footprint by 50%, so we built in the time and attention to take advantage
of those savings and to do something good for the environment.
We also listened carefully to user groups that consisted of previous patients, (both satisfied and unhappy
patients), and they evaluated designs within a broad context. This helped us understand what they did
and did not like about their previous stay with us at our old hospital. All of that input was a part of the
discovery process.
Finding perfect alignment between all of your user groups is never going to happen, but convening and
listening to these groups is still a very worthwhile process. There are economic drivers which can impact
your decision-making in a very tangible way, so we found user group input needs to be very specific.
We could then carefully analyze their feedback and understand the underlying issues that needed to
be addressed. We did not want to assume we knew what patients wanted.
If you acknowledge that there is a political side to the decision making process, then you can navigate
it. It is important to be clear about that. Various stakeholder groups will drive the bus on occasion,
but as much as possible, it’s important to manage the process and keep coming back to your guiding
principles as a compass. When you do this and acknowledge and manage the politics that are inherent
in a major undertaking, it will drive you toward success.
It is important for all stakeholders to take ownership of the project, keeping in mind that eventually
they will move into the new facility and have to begin functioning in that space. Adjusting to factors
such as having a larger patient population, working with new equipment in new space, and embracing
new policies and procedures – these were some of the challenges faced by our team. While we
trained everyone for transitioning to the new environment, it is never seamless, no matter how much
preparation you have, so it is crucial for them to embrace change and remain committed to providing
excellent patient care.
And risk management? How did you mitigate risk to the best of your ability?
The amount of risk with this multi-year project was quite extraordinary, so we planned the best that we
could, involving the best professionals we could, to help guide us at every phase. We were acutely
aware that there were many factors to this project that were outside of our control.
For a project of this magnitude, with so many factors that could significantly impact our outcome, we
built in a significant financial and time cushion for contingencies. For example, the day that we broke
ground, we experienced the biggest stock market drop since the depression. Fortunately there is an
upside to that incredible timing. As it turned out, with the construction phase aligning with the tanking
of the economy, it allowed us to leverage pricing opportunities during construction that might not have
been otherwise available to us.
Those kinds of macro factors in the environment will impact your project, so it is crucial to have sufficient
contingencies and cushions before taking on a project like this. There are things that you could never
plan for, and your cushion will see you through them.
You also have to be willing to not do the project if it is not the best thing for your organization and
the people you serve. This is a huge responsibility and decision to make. As you are going down this
road, when the time comes to move forward and borrow the money to buy the land and make that
commitment, you will have probably become so vested in the project that it would be hard to pull back
if that is the right thing to do. It requires a dispassionate perspective to make that final decision.
For example, we had to put the project on hold for six months until we obtained the capital necessary to
undertake and completely finish the project. That was the right decision for us at that time. It is tough,
but you have to be willing to do the right things and say no, and have the contingencies in place to
weather that kind of change in plan if it becomes necessary.
What was the one thing that kept you awake at night when you started making those early
decisions on the project?
No one on the hospital side had this kind of previous experience, so we turned to the design and
construction professionals for expertise. Your burden is to educate us [your clients] very early in the
project because so many important decisions are made at that time. In fact, you are learning at the
same time that you are making the most crucial decisions. That is why it is absolutely crucial to have the
entire design team on board at that point.
There is an inclination to focus on each team member’s area of attention. With everyone at the table,
there can be a dialogue about what our stakeholders need versus what they want, and the aesthetics,
functionality, and constructability of the design.
When engineers are involved from the outset, they are able to move that great engineering idea
through the phases when they are most vulnerable to being value engineered out or sacrificed for
aesthetics. But don’t get me wrong, aesthetics are important too. They matter to the degree that the
community keys off of aesthetics as an indicator of the quality of attention that a hospital pays to their
environment. Some patients will choose one facility over another one based on aesthetics, so it is an
investment in marketing and attracting patients and decision makers.
So there is a balance that needs to be struck, between aesthetics and functionality. A good, collaborative
team will do both.
What would you like for engineers to understand about undertaking a project like this?
It is a communications thing; engineers sometimes talk about design in a way that doesn’t seem to
relate to the things that matter to us. What matters to us are things like patient and visitor experience,
nurse recruitment and retention, therapists’ and surgeons’ ability to contribute to the best possible
clinical outcomes.
We need for you to explain the ramifications of the decisions that we face. Whether they are clinical,
operational, and/or provide for future flexibility, make sure the client fully understands the options that
are available so we can make those informed decisions. Remember, my focus will always be about
user response to conditions that you create as engineers. Those users might be patients, physicians,
employees, visitors or others.
Is there a single lesson learned that you believe was critical to the success of your medical
center?
This hospital is unusual in that we built three patient room mockups, which were entirely functional
mockup patient rooms and we worked in them for more than a year. Patients stayed in them and
received care. We gathered input from; patients, nurses, therapists, visitors, and physicians. All were
interviewed about their experiences and their input was used to make improvements to the design.
That was one of the very best investments we made in the planning of our hospital. We were fortunate
to receive generous funding for this initiative from the Robert Wood Johnson Foundation. We have
shared our findings with other hospitals.
Is there one thing that stands out in your mind from patient response to your new hospital
building?
Sure. Our patient rooms feature a television-based interactive tool that gives our patients the ability to
provide daily feedback on their perception of the healthcare they are receiving as well as our overall
hospital performance. The only negative comment in our single patient rooms that we heard was that
the numbers on wall clocks in their rooms are too small to read.
Really? Did you do anything about that?
Well we changed them, of course! We would not let a minor thing like that get between us and our
patients’ positive experience.