It is not easy delivering 21st Century health care in facilities a century old.

Renovations and updates are possible, but as Reid Hospital & Heath Care Services in Richmond, Ind., decided, sometimes it is best to start from scratch.

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The hospital in the state's east near Ohio is building a $233 million replacement complex on a greenfield site about 2 mi. north of the existing hospital. The project will serve multiple purposes, making room for the latest technology and trends in health-care delivery and allowing the hospital to enter into new partnerships with its physicians.

"This is the biggest thing to hit Richmond probably since the first hospital was built 100 years ago," said Michael Doiel, senior vice president of Chicago-based HDR Architecture, which helped Reid evaluate its expansion options and designed the new facility.

HDR was hired in 1999 to assist Reid officials in the process of evaluating its facility's needs and options. Doiel said the visioning and planning process resulted in five options, ranging from nothing to upgrading existing facilities to replacing them onsite to starting over on a new site.

All of the options required substantial investment, and hospital officials eventually determined that the most drastic-seeming option was actually the most cost-effective.

"Going to a greenfield site will be 25 percent less costly," said Ted Sobol, Reid senior vice president. Renovating the existing building piecemeal would have been costly and disruptive to the staff.

Work at the new site began in summer 2004 on a heavily vegetated site. Soil surveys revealed the need for lime modification for stabilization. Contractors then worked through the winter putting in auger cast pilings to support the hospital.

Workers celebrated topping out in December. The medical office building and outpatient-care center are to open in spring 2007, followed by the hospital tower in the late summer.

A Good Partner

HDR found Reid's officials to be eager partners in the design process, Doiel said.

"They believe in collective decision-making," he added. "They really wanted consensus-building decisions across the board, from the vision all the way to the type of plantscape outside the building."

Hospital and HDR representatives visited numerous other buildings as they pondered the new facility's design. They even took a bus tour to the southern Indiana community of Columbus, well-known for its large collection of buildings designed by leading architects.

"They like a lot of the traditional design elements and some of the history that goes back to the existing facility, but then again they like some of the contemporary geometry, like the curves," Doiel said. They settled on a style they termed "soft contemporary," marked by richly colored red brick, precast accents, curves, curtain wall and cantilevered canopies.

The new Reid complex consists of a total of four buildings, though the first to be completed is a 4,200-sq.-ft. maintenance building, said James Beckelhymer, senior project manager for the Indianapolis office of general contractor Turner Construction Co. That building was completed first and is being used temporarily to house construction offices.

The remainder of the facility includes a six-story, 544,000-sq.-ft., 233-bed patient tower; two-story, 136,000-sq.-ft., outpatient-care center; and three-story, 66,450-sq.-ft. medical office building.

The three buildings are connected along the front by what Doiel called a "main street" as well as a connector in the rear, which allows physicians and employees to move easily from building to building.

Though the hospital will not have any more beds than the one it is replacing, Sobol said the facilities will be a major improvement. For one thing, all rooms will be private.

"We'll be expanding the size of each patient room, and services will be much closer together," Sobol added. "Patients at our current site have had to move all over the building to get various services. It will also allow us to greatly expand our cardiovascular services program and our oncology program."

The design of the complex was influenced by the creative financing that Reid officials arranged.

A key goal was allowing greater physician involvement, but health-care financing regulations prohibited physician ownership of certain aspects, including the main inpatient hospital tower of the not-for-profit hospital. The hospital could, however, establish partnerships with physicians to provide outpatient surgery and other services, as well as the ownership of the medical office building.

Reid established a number of financing instruments that gave physicians a stake in the project, including unusual participatory bond transactions, a joint venture that owns the medical office building and a management-services organization that physicians can buy into and then earn rewards for helping the operation meet specific efficiency targets.

Sobol said about 70 physicians have invested in one or more of the alternatives.

Outpatient Services Stressed

Doiel said that because more services are being delivered on an outpatient basis today, numerous models for outpatient service delivery have evolved - in the hospital setting, in a clinic setting and in joint ventures involving hospitals and physicians.

"We decided that we needed to provide all of those different models on one campus," he said.

The master plan called for offering such outpatient services as surgery, radiology and cardiology, services that also must be available to inpatients without sending them to the outpatient-care center.

HDR's solution: The surgery area of the inpatient tower backs up to the outpatient surgery center.

"The ambulatory surgery center is on the other side of a wall from inpatient surgery," Sobol said. The same is true with radiology and cardiology services. All are in close proximity, a convenience for physicians, but the inpatient and outpatient services are technically in separate buildings to satisfy legal requirements.

The buildings are constructed of structural steel and composite decks, Turner's Beckelhymer said.

"We are in a high seismic zone, so the buildings are designed for seismic conditions," he added. That meant the use of drag-steel elements to provide more rigidity, as well as extra bracing and anchoring for mechanical, electrical and plumbing systems running above the ceilings.

The diagnostic, surgical and patient areas were designed with extra-large floor-to-floor measurements of up to 16 ft. to allow for the high mechanical, electrical and plumbing demands typical of a health-care facility. Those include medical gases and vacuum along with sophisticated heating, cooling and ventilation systems.

"In a hospital, it runs about 40 percent of the cost of the building for the MEP systems,"

Beckelhymer said. "With all of those systems, it takes a lot more coordination to install. We did detailed coordination drawings for above the ceiling showing who goes first, second and so forth."

Reid officials' desire for active involvement led to the extensive use of mock-up rooms, which were built in a courtyard near the existing hospital's cafeteria to allow as much participation as possible.

"We tested and retested those rooms and spent a lot of time in there," Doiel added.

Further mockup work is being done onsite as well. For each of the common room types, contractors will finish one room early, allow an opportunity for alterations and then work on all rooms of that type using the final design.

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