Montefiore Medical Center's Ambulatory Care Center

Montefiore Medical Center | PAGE 1

Montefiore Medical Center’s Ambulatory Care Center

Designs Delivered

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

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PAGE 4 |Designs Delivered

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.

Today’s facilities need to work with tomorrow’s technologies. The

current and future trends in ambulatory care underscore the high-

growth, 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.

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

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.

https://www.advisory.com/daily-briefing/2015/09/08/design-showcase

https://www.advisory.com/daily-briefing/2015/09/08/design-showcase


“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


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 patient-

centric 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.



Lean Design

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

Lean Design Approach was imperative to understand how clinicians

and staff could work—and how information and patients could

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

Lean Design Approach on quality and cost were essential to allocate

resources appropriately and to stay within the project schedule.

A Lean Approach was also essential for delivering this complex

structural project within budget and for meeting the aggressive

schedule by organizing all project phases and promoting coordination

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

engineers, construction manager and trade contractors. Another

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.

This also expedited other field trades such as electrical

subcontractors. Because the model so accurately reflected the actual

construction, snapshots of different columns could be extracted

from the model, measuring distances between all columns, allowing

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

of transitions and saved significant time.

The model was developed to support actual construction sequencing.

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

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

model contained color-coded materials that corresponded to a color

when delivered to the site.

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.


“We essentially had a box that we had to make everything work in...But it’s a lean approach to design in the sense that we wanted to reduce the number of steps as much as possible, as people go from point A to point B.” - Jason Lee, Project Manager

quoted in Outpatient Surgery Magazine


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.


“… 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

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.


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 patient-

centric experience.



Surgical Environments

Montefiore’s vertical configuration necessitated that the Surgical

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

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

ORs are equipped with electronic bedside registration and charting

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

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

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

SURGICAL SUITES

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

to support procedures and is looped back to the Central Sterile

Processing Department by dedicated elevator transport. A clean core

with direct vertical transport that leads directly to the clean central

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

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

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.


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

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

suite including endoscopy space. Also occupied on this floor is

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

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

maintain the one-way flow to the clean environment.

The design of a flexible ambulatory OR was key in allowing the

most efficiency in scheduling OR block-times. At approximately

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 ceiling-

mounted equipment. A Kruger system air curtain completes the

infection control protection of the surgical field.

RECOVERY

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

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

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

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

recovery bays to enhance the mind-body connection and encourage

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

privacy with custom designs while offering an open, connected feeling with

unobstructed views from the nurse station.


CENTRAL STERILE PROCESSING

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

Whether within an inpatient facility or an ambulatory center, the

location, flow and size of the Central Sterile Processing Department

(CSPD) affect adjacent spaces, as well as

a facility’s overall effectiveness. We do not

stop at planning and design of the facility,

clients call upon our expertise during staff

training and after occupancy to refine flow

and optimize the service the Department

delivers internally.

Knowledge of equipment specifications

and procedure/surgical instrumentation

needs as well as our dedication to listening

to the users of each facility, provides us the

expertise to assist our clients at all phases

of their Central Sterile process.

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.

This review uncovered the delivery frequency of certain supplies,

their weight and footsteps taken to their shelf

location. A flexible storage model allowed us to

adjust the layout in the CSPD with a continuous

improvement model (PDSA – Plan, Do, Study,

Adjust), to achieve maximum efficiency. After

the first layout was completed, the staff studied

it for a week. During the second review session,

further adjustments were made prior to the start

of the first surgical case.

Two weeks after the first surgical cases started,

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

supply of information and frequency of use were

determined, additional adjustments were made


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

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

the clean elevator for high frequency supply replenishment. Teaching

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

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

surgical services develops and as their needs grow.

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

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

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

greater efficiency and workflow when sorting instruments.

Another technological improvement for the OR and CSPD is radio-

frequency identification (RFID) technology. As instruments pose a

high dollar amount to the surgical services budget, equipping the

surgical service areas with radio-frequency identification technology

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

but it will also help in tracking smaller surgical instruments reducing

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

RFID technology can be embedded in the smallest instruments for

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

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.

While technology alone will not ensure the most efficient turnover

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

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

OR throughput model.

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


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.

Click hereto view Top 8 Considerations When Redesigning MRI Suites

http://blog.array-architects.com/kc/top-8-considerations-when-redesigning-mri-suites



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

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

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

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

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

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

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.

When designing the MER, several restrictions and considerations—

planning and design coordination, MER location within the building,

the MER environment, protecting adjacent areas and unit removal—

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

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

step process.

The first step involved analyzing the space that the ambulatory

surgery program needed within the total floor space. It quickly

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

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

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

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

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.

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

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

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

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.

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

design and coordination. Healthcare facility MER designs are detailed

and involved, with various crossovers, interconnections and layers

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

design the ductwork? Most importantly, what are the clearances

and service access points? During concept design, the specific

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

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

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

wasting valuable floor height?

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

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

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

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

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

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

Utilizing BIM and coordinating with the MEP and CM enabled the

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

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

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

ductwork or conduit—to identify where duct overlaps could occur

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

clearances and maintenance access.

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

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

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

adjacent areas.

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

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

high Sound Transmission Criteria and that our Noise Criteria was kept

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

Mechanical Organization


“...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


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.


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Montefiore Medical Center's Ambulatory Care Center