How to Remake a Hospital . . . details, details, details
What does it take to build a hospital, Emory-style? Involve the physicians and staff who will use it, pay attention detail by detail, spend now rather than pay later, and seize opportunities in unexpected places.

by Marlene Goldman

Jack and Beth Morford's third child arrived last November at Crawford Long Hospital. While the couple says that quality of prenatal care was first-rate, getting to it could be daunting. After skirting closed or rerouted streets, Beth was lucky to find parking a block away before braving her way on foot across four to six lanes of traffic to her doctor's office in the West Peachtree building. It didn't take her long to figure out the true value of valet parking. Still, to get an ultrasound or other tests, she had to leave her doctor's office and walk across the street, often dodging construction trucks and workers.

As his wife's "coach" and the proud father of Parker Morford, Jack couldn't help but take mental notes. In the months before his son's arrival and during those long hours of labor, he experienced firsthand (in all ways but one) what it was like to have a baby at Crawford Long. As an Emory employee and member of the redevelopment team for the largest medical construction project in Georgia, Morford had spent countless hours with physicians, staff, and architects helping iron out the details of 11 labor and delivery rooms and 36 mother-baby suites that will be part of Crawford Long's new state-of-the-art birthing center.

It will reside within a new, more patient-friendly Crawford Long tower that will open in 2002. To get there, patients and visitors will no longer have to navigate a maze of hallways and tunnels or cross busy streets. Expectant parents will park in a nearby deck and walk across a covered, climate-controlled bridge to a six-story diagnostic and treatment center topped by a 14-story medical office building. Once there, they will take an elevator to see their physicians, take tests, and eventually even have their babies.

By 2003, the aging Crawford Long medical complex that now blankets four blocks of prime Midtown real estate will have been refashioned into one superblock. Its centerpiece 20-story, stone-and-glass tower will look and feel like a five-star hotel, planners say. A concierge will greet patients and visitors as they enter a three-story, glass-enclosed conservatory with public lobbies and waiting areas surrounded by lush greenery, fountains, and seasonal flowers. But "getting there" is key. The redevelopment also focuses on public spaces and how people move around in them. New sidewalks, lighting, open space, and a park-like setting will complement the vision of Central Atlanta Progress and the Midtown Alliance, two prominent local business organizations. A new parking garage, complete in the third phase of the project, will provide better access for patients and visitors. There will be a secure walkway from the nearby MARTA Civic Center Station.

View from the war room

Sneak previews

The Crawford Long redevelopment team
took some extra steps to insure that
what looks good on paper works in the
real world. After learning from staff of
each relocating department how they
worked, what spaces they needed, and
what particular challenges their work
presented in terms of space, the builders
created life-sized models. "We realized
that many people just can't read and
visualize plans on paper, so we created
mock-up rooms for them to actually
walk in and work in," says David Pugh,
who heads the redevelopment team.

Staff toured models of an operating room,
a neonatal intensive care unit (NICU), a
recovery room, postpartum, labor and
delivery, and special procedures rooms,
and then evaluated design and function
-ality and suggested changes. They
critiqued casework, medical gases,
electrical outlets, fixed and movable
medical equipment, furniture, lighting,
and plumbing.

By the time the operating teams, including
surgeons, tried out a model OR (com-
plete with table, anesthesia equipment,
lights, and medical gas columns), they
already had spent months in animated
discussions about the relative merits of
different configurations, even where to
put the doors. "Nurses wanted a place to
set up, anesthesia needed room for their
equipment, surgeons needed elbow room,
and we all needed to be able to bring
patients in and out without there being
any barriers," says Jane Vosloh, nursing
director for perioperative services. "Tech-
nology has changed a lot too, and equip-
ment like video monitors and lasers take
up room. So we had to work through
where we were going to place things and
how patients would come into the room.
After going through the model, we literally
ended up moving some doors. It was much
more economical to change it now than
have to make changes after it's already built."

The end product will include 22 operating
rooms that are larger than the current ORs.
Octagonal-shaped corners will help maxi-
mize space and storage both inside and
outside of the room.

The models also were especially produc-
tive for the Crawford Long physicians,
nurses, and midwives who will staff spe-
cial care nurseries. An isolette originally
placed in the middle of each NICU allowed
too little space for the caregivers, who
prefer to stand on the same side as the
parents. The NICU was later redesigned.

Even though the models helped identify
potential glitches, changes in health care
will affect future spaces. "One of the
most difficult tasks is how to plan for
medical equipment changes," says Katie
Smith, a member of the redevelopment
team. "For example, we expect MRIs to
change in the coming years, so how do
we plan for electrical or mechanical
requirements for those now since we
don't know what those changes will be?
We've got to keep the new spaces
flexible enough to tweak them if we
need to."

Anesthesia Services Director Arnold Barros
(right) explains the layout of a new OR.
Photo by Stacie Stanley.

While it took nine months for Parker Morford to make his appearance, the decision to redevelop the third largest hospital in Georgia came after almost three decades of deliberation. Now more than two years into the project, Emory Hospitals CEO John Henry says its ultimate success rests on paying attention to details. It's an opportunity to go beyond bricks and mortar, to rethink how physicians and staff provide care and other services, with the overall goal to increase efficiency at all levels.

Command central of the redevelopment is a spacious former dentist's office on the 11th floor of Candler Building A, a historic structure which now houses many of the physicians who practice at CLH. One full wall of windows overlooks the construction site, where a giant crane moved 1,250 tons of steel, half a million square feet of form work, and 23,000 cubic yards of concrete shaping the tower that will house the new medical office building and diagnostic and treatment center. Dotting the "war room's" other three walls are blueprints, schematics, schedules, organization charts, and colorful renderings. The floors abound with tile samples, color charts, and carpet swatches. A model of the finished project sits on the conference room table.

Most days, this room hosts a whirlwind of meetings with architects, engineers, project managers, consultants, and the developer. They have picked the brains of more than 120 staff and 100 physicians to analyze new spaces and how they will work -- from the layout of rooms and the adjacency of the 13 departments slated to move into the new facility to public areas and how physicians and staff will navigate the new spaces to provide care. Team leaders were asked to think ahead two years from now: how they would use their spaces; where each electrical outlet, each sink, and light switch needed to be; what furniture and other elements would make their areas function well.

The planners have also learned from the experiences of other hospitals. During site tours in other major cities, Crawford Long teams not only looked at buildings but how those hospitals organized to strategize everything from planning the project to operations and move-in. They asked their counterparts at other hospitals what they did when they built or remodeled, what they didn't do, and what they would do differently.

Involve physicians and staff from the start, they were advised. Carefully select architects, engineers, the developer, and the general contractor.

"We contracted with firms because of their people. We think of them as our partners -- people we were going to have to live with for three years," says Henry. "So we asked to interview those directly involved with the project -- the project managers, not the presidents or CEOs of the company. We wanted to know who would be here on day 1 and at the end of the project, and that's made for an incredible team.

"We wanted an architect like HKS, one that didn't merely regurgitate back our ideas, but could offer us fresh ideas and new ways of doing things. And we needed a developer like Cousins Properties to help us coordinate this project. We wanted a builder like Beers Construction who knew how to put together a complex structure and keep to a timeline."

That approach has paid off, sometimes in unexpected ways, says Henry. "Cousins, for example, sold the 203,000 tons of dirt that came out of the excavations for the tower. It went to other construction projects, including the CDC and Columbia Middle School in DeKalb County. Concrete from the Glenn Building demolition was reused in other parts of the project, and we recycled 300,000 pounds of steel."

The redevelopment team refined other ideas gleaned from the site tours. For instance, all operating rooms will move to the new diagnostic and treatment center, but intensive care beds (along with all other inpatient beds except maternity beds) will stay in the existing hospital. Patients who need special care after surgery will stay in an intensive recovery area adjacent to the new ORs and will not be moved until they are stable.

Besides patient care, the redevelopment project has presented opportunities to help all Emory Hospitals operate more efficiently, in areas such as food services. As part of the project, the kitchen in Crawford Long's existing hospital is being reconfigured into a bakery that will supply all Emory Hospitals and Wesley Woods. Emory University Hospital will handle most of the other cooking, then "blast-chill" and transport it in bulk to the other hospitals, (including the Center for Rehabilitation Medicine, mental health services, Wesley Woods Hospital, and Budd Terrace) where it will be heated and served. Transporting the food is expected to cost less than running two kitchens. (And the redevelopment team insists the fried chicken will still be the best in town.)

"We're being opportunistic here," says Tony Wimby, an associate administrator who oversees food and nutrition services. "Since we were already building a new kitchen, we decided to go ahead with this cook-chill system, which a lot of restaurants use. We expect a big payback over the next few years -- not only in dollar savings but in the quality of food."

The planners have taken advantage of other opportunities as well. When they discovered that the water table on the construction site was relatively high, they decided that an emergency well will be dug in case the hospital loses city water. "Losing city water in a hospital puts your operating room in jeopardy because you can't provide cooling," explains David Pugh, who leads the redevelopment team. Much of the hospital's equipment will be water-cooled. The well may also be used to water the new 2.5-acre park to be created when Candler buildings B and C (currently medical office buildings) are torn down.

Business as usual?

Thousands of details have been hashed
out in the war room overlooking the
construction site. Photo by Stacie

Just the facts

The Crawford Long Hospital
Redevelopment Project

Project scope

Construction of a 20-story tower which
will house:

  • a six-story, 500,000-square-foot
    diagnostic and treatment center
  • a 14-story, 365,000-square-foot
    medical office building

Renovation of the Davis-Fischer and
Woodruff buildings

Construction of the Agnes Raoul Glenn
Building devoted to hospital and com-
munity education and radiation and
medical oncology

Two parking decks

Total  cost: $270 million

Timeframe: Start May 1999;
Completion Summer 2002

Parking and patient access have driven many of the decisions of how to operate during construction and even how and when to build buildings. With eight buildings scheduled to go under the wrecking ball by the time the project is done, planners have had to play musical chairs with some 40 physicians and hundreds of employees in 15 departments who have been temporarily displaced. Besides finding a place to put all these people, there were other concerns: How would relocated departments get their mail? Or new telephone numbers? How would patients coming to Crawford Long find their doctors, or get tests done in temporary offices, or navigate construction sites safely?

"The goal," Henry stresses, "has been to provide business as usual."

With persistence and some creative shuffling, the redevelopment team preserved some services that the community depends on and provided better space for some departments on the move.

"For example, at first we thought space was too tight to continue to operate the auxiliary thrift shop," recalls Pugh. "Then we realized how important it is to our employees and the community. So we found a place for it. More difficult was finding a space for years of Emory Clinic medical records that weighed about 70 tons. We went through every building on and around the Crawford Long campus - bank buildings, even abandoned parking lots - then discovered that the basement of the West Peachtree Building (the former nursing school building) with some additional support could handle the weight and provide more space."

Rather than lose 200 parking spaces by putting other dislocated departments and physicians in trailers in the Linden Avenue parking lot across from the hospital, the West Peachtree Building was renovated to temporarily house 25 interim physician offices as well as five administrative departments of the hospital. The decision to renovate rather than build temporary modular units saved $1 million, but even more important, provided better patient access by saving the parking lot and later adding a new one further down Peachtree Street. Shuttles now run every five minutes and take patients and visitors throughout the campus. Originally scheduled for early demolition in the three-year construction project, the West Peachtree Building now will be one of the last to come down.

In some cases, the moves have made getting treatment easier for patients. Radiation oncology's linear accelerator, which last year treated more than 400 cancer patients, was housed in the Agnes Raoul Glenn Building, the first structure to come down in the process. CLH faced losing its certificate of need if the facility was out of service for more than a year. While initial projections scheduled nine months to build a modular building with 7-foot-thick walls to house the accelerator, the new facility was up and running within five months. Patients say the new site is much more convenient.

Tearing down buildings and relocating departments have presented other challenges to patients and employees alike. "Imagine working here for a long time or going to the same doctor in the same office for years, then discovering that everything has moved," says Stacie Stanley, public relations manager for the redevelopment. "We sent out mailings detailing our plans to all patients, doctors, and employees. We met with managers to determine how to best communicate changes; we created new maps, signage, and a newsletter to keep employees updated on the building's progress."

One of the early and ongoing tasks of the redevelopment has been keeping the community informed about the progress of the project and any activities (such as the implosion of the Glenn Building to make way for the office tower) that might affect traffic or safety or impede business.

"This project has been an opportunity to reintroduce an old friend to Atlanta," says Debra Bloom, assistant administrator for institutional advancement. "We're presenting not only a new building, but a friend who has a new look, a new attitude, and new promise."

One concern, though, has been how three years of construction would affect admissions. Could CLH survive such an upheaval?

Yes, says Albert Blackwelder, chief operating officer of Crawford Long. "Admissions are up. We're packed." New doctors have come on staff as well and will move into the new medical office building when it opens.

Moving day

Why now?

When the Crawford Long Hospital redevel-
opment project received the go-ahead in
1998, Emory Hospitals CEO John Henry
was asked what kept him up at night.
"Doing nothing and letting the city and
our competitors grow without Crawford
Long changing," Henry replied.

Since it was founded in 1908, Crawford
Long has grown incrementally into a
hodgepodge of buildings plunked in the
middle of what has evolved into one of
the hottest neighborhoods in Atlanta.
Most of Crawford Long's nine buildings
are more than 25 years old, 16 years
older than the nearest competitor, and
the hospital spends close to $10 million
a year to maintain and retrofit them for
modern health care practices and equip-
ment. The campus is not patient friendly,
and physicians practice in outdated, in-
efficient buildings that are inconvenient
to diagnostic and treatment services.

Faced with shrinking federal reimburse-
ments, more managed care, higher opera-
tional costs, and more charity care, it has
become increasingly critical to the hos-
pital's survival and to Emory Healthcare to
create a facility that is more efficient to
operate, more attractive to patients, and
more accessible. In fact, the efficiencies
and savings from the new facility are
expected to completely pay the costs of

That's good news for Emory Healthcare.
Crawford Long is a strong tertiary care
referral site for Emory Healthcare and
provides financial and academic support
for the medical school and university. In
other words, what's good for Crawford
Long is good for Emory and our patients.

Moving into a new building is like moving into a new house, Morford says. "You look it over to figure out where everything is -- the lights, the air conditioner, the bathrooms. It's the same for a new hospital: you can't work in it until you know where everything is and how it works."

That will mean orienting 2,100 staff members and 1,100 doctors as well as the 100,000 patients who seek care at CLH each year. Last fall, departments began studying the layouts of their new spaces and planning their move-in strategies. Seven transition teams began work in March to ready for the move, making sure operations continue unimpeded, educating and orienting staff, and keeping communications open during the yearlong process that will culminate next spring. The key is following a detailed moving plan and timeline to maintain quality of care.

In June, close to 150 administrators, department leaders, and transition team members listened to hospital-wide "assumptions" of how things would work in the new building. How would medical records be stored or retrieved? Where would security be located? When and where would trash be collected? How would food be delivered to patients? Where are the telephones and fire extinguishers? Where are laundry chutes?

"The new spaces have allowed us to group more related functions together," notes redevelopment team member Katie Smith. The birthing center and neonatal intensive care unit (NICU) will be on the same floor; the ORs will be near the blood bank, satellite pharmacy, and central supply; and the emergency department will find radiology close by. The new, more accessible locations, however, require rethinking staffing, policies, and procedures in keeping with the new spaces and new programs.

Radiology, for example, will move from eight locations spread across three city blocks to one floor of the diagnostic and treatment center with only one reception area. Wait times will be reduced drastically by putting all technologists together. The department is also eliminating traditional films, so that techs and physicians can look at electronic images at the same time. To help radiology handle all these changes, industrial and systems engineering students and faculty from Georgia Tech worked with radiology to reconfigure the department's workflow.

The emergency department will triple its current size, providing for growth and new services such as a clinical decision unit -- an eight-bed observation unit that will provide caregivers time to assess patients rather than admitting them immediately to the hospital.

Even though Crawford Long has been delivering babies for 90 years, physicians and staff will have to relearn how they operate and communicate in a new birthing center with triple its current space now spread out in four units of the hospital. "In the current NICU, we've been trying to do modern medicine in a 60-year-old building," says Ann Critz, chief of pediatrics. The new birthing center promises a very different experience. After having their babies, mothers will be moved to a mother-baby suite on the same floor. Babies who need special care will no longer have to go to a different building, away from their mothers' rooms. The new NICU will be on the same floor as the birthing center, and parents can stay close by in special rooming suites with monitors connected to the baby's room.

With a total of 22 operating rooms and two cystoscopy rooms, physicians and staff of surgical services will also have to learn how to live and work in a larger, more efficient space. "Inpatient and outpatient surgical suites are designed to maximize convenience and flow for patients, visitors, and staff," says chief of anesthesiology Peggy Duke. The designers especially considered preferences of OR staff who currently spend hours in the operating room with no natural light. The new design includes windows for outside light. The 32,000-square-foot outpatient surgery suite will be conveniently located on the lobby level and include six operating rooms, one cystoscopy room, and a procedure room.

"A new building that will be the hub of patient flow will give us the opportunity to look at the work flow of every department involved," says Alice Vautier, chief nursing officer. "It is a wonderful time to look at what has worked well, what has been labor intensive, and how we can redesign our work."

"As soon as the paint is on the walls, we'll start taking staff through their new spaces so they can see the layout," says project coordinator Amy Simons. "Then all hospital staff will tour the new building, before we start the patient and visitor tours."

Before moving day, all departments will try out their new environments with mock patients. Staff will test codes and new equipment and make sure everything works, even check which ways the doors open and where the bathrooms are.

"With such planning and preparation, we're sure to have a successful move," says COO Blackwelder. "But we'll still spend some time afterwards evaluating the process and making improvements if necessary."

Going for the 'ah!'

CEO John Henry adds his signature to a
steel beam signed by hundreds of Crawford
Long employees. Photo by Stacie Stanley.

Every Monday morning, rain or shine, Emory Hospitals CEO Henry walks the construction site with the redevelopment team and asks questions, challenging, taking in even the smallest details. At night, he often pores over plans at home. He is an advocate for life-cycle costing -- spending more up front to keep maintenance costs at a minimum over the long haul. Inside and out, that philosophy is evident.

"That's why the exterior is stone and glass, that's why we put in marble floors in the lobby because marble will be with you forever, as opposed to carpet that has to be replaced every four or five years," Henry says. Aesthetics are part of that functionality too, including unified colors throughout that won't be outdated next year and furniture that is durable as well as attractive.

The "skin" of the building, for example, was originally designed to be 90% glass and the rest, other materials. Heeding trustees' concerns that the facade was too modern and not in keeping with the rest of the Midtown area, the architects redesigned the building to be 60% stone and 40% glass. "Not only did we get a better design and better building, it allowed us to save money that we have used in other areas," Henry says.

Since he and his wife, Barbara, survived the MGM Hotel fire 20 years ago in Las Vegas, Henry has had a particularly personal understanding of the importance of safety. The new structure will exceed safety codes. "I'm most interested in making sure we design and build this so that it's safe," he says.

In this Issue

From the Director  /  Letters


How to remake a hospital


Moving Forward  /  Noteworthy

On point: Healer or line worker?

Nation at a crossroad

Today, the Crawford Long redevelopment project is under budget and ahead of schedule. The medical office building will open by the first of the year. The rest of the building is expected to be ready next summer. Henry has high expectations for the finished product to be a better place for patients and their families, physicians, and employees.

"I want physicians to feel that this is the best place for them to work and care for their patients. Doctors will be able to drive in the parking lot to their space, go to the office to make rounds, go to surgery or any other area, and back to their office without ever having to move their car. Patients will be able to do the same because everything will be vertical.

"When it's over and done, I want people to walk into the J. Mack and Nita Robinson Conservatory and say, 'Ah!' I want them to be totally bowled over. I want them to feel that they are in a place of healing with friendly folks, who really care about them as individuals and will give them the best care possible."

To learn more about the Crawford Long redevelopment project, see

Marlene Goldman is editor of Momentum.


Copyright © Emory University, 2001. All Rights Reserved.
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Web version by Jaime Henriquez.