Hospitals Undergo Reconstructive Surgery - Many of Region's Medical Centers are Bulking Up | The Boldt Company

Even under normal circumstances, hospitals are among the most complex projects a contractor will ever tackle.

Modern medicine requires walls to be wired and plumbed so that monitoring machines and air hoses can be plugged in right at the bedside. Proper airflow is critical to prevent the spread of infections. State regulations require new hospital construction to withstand a major earthquake, a much higher standard than for offices or residential buildings. All the power systems must have backup supplies.

"Every major system needs to be anchored and braced in a very specific way," said Mike Boyd, executive director of Facilities Design and Construction at UC Davis Medical Center.

In older buildings, data equipment might have been relegated to an old closet. Today the volume of equipment requires special air-conditioned rooms.

Now try tackling a major hospital renovation and expansion in the middle of an urban area, with heavy street traffic that limits delivery and storage of materials. Both Sutter Health and Catholic Healthcare West are working under these constraints as they upgrade in midtown and East Sacramento.

Congestion influenced the design as well as the construction of Mercy General Hospital's new Alex G. Spanos Heart & Vascular Center in East Sacramento. Before work could begin on the new building, Catholic Healthcare West had to assemble a land deal that involved replacing nearby Sacred Heart Parish School and several houses.

Once the heart center is up and running, Mercy will tear down its 1950s-era East Wing, shrinking the hospital from 171,246 square feet to 123,350 square feet.

"When developing the EIR for the project, we looked at a number of alternatives including a brand new site. Since the heart center is only one wing of the hospital, the best alternative was to stay at the current location versus rebuilding the entire campus elsewhere," said Jeremy Schrimsher, Mercy General's vice president for ancillary services. "Also, we felt that this would be a good example of a smart growth infill project for the Sacramento community."

Surrounded by residential East Sacramento, Mercy worked with the city and the state Department of Transportation to develop a traffic management plan. A shuttle service transports many employees to offsite parking lots and to the light-rail stations at 29th and 39th streets. The shuttle is open to the public, too.

Inside, the heart center will feature a hybrid surgical suite that relies heavily on imaging equipment. Operations that once required large incisions can now be done through smaller openings, or even with just a catheter. But they also depend on tiny cameras and sharp screens to give doctors a view into the body.

‘A TIME OF GREAT UNCERTAINTY’
About a mile away on the edge of midtown, Sutter General had an extra hurdle to clear: It changed general contractors in midstream and with no pauses for regrouping.

"That's the hardest part. You've got to get a grasp of where the project is currently at, and what remains to be completed," said Dave Kievet, group president of The Boldt Co., which took over from Turner Construction in 2009. Turner had been on the job since 2003. At that time, work was about 70 percent complete on Sutter's new combination medical office building and energy center, about 40 percent done on the remodeling of Sutter General Hospital, and just getting started on a new women's and children's center to replace Sutter Memorial Hospital.

Boldt had to review existing contracts, make sure liability insurance was all in place, keep up morale among the subcontractors and keep the work on track.

"We really didn't want to walk into the project with the attitude of there's a new sheriff in town," Kievet said. "It was a time of great uncertainty for a lot of the trade partners who were on the job already. We did make a few changes on the project as far as the team members, but we tried to communicate with everybody."

That included daily sessions where Boldt's own team could vent its frustration, and a similar series for subs to do the same.

It was the first time Boldt had waded into a half-finished project.

"It's one of those things that if we knew what we were getting ourselves into, we might have made a different decision," Kievet said. "On the flip side, it was really exciting for everyone."

The excitement includes digging tunnels, closing major midtown streets and building bridges between buildings.

"We have bent over backward repeatedly to be a good neighbor, recognizing the disruptions we are causing," said Larry Maas, assistant administrator in charge of the Sutter Medical Center master plan. Steel, concrete and other materials don't show up on site until immediately before they are put into place.

Workers start pouring concrete at 2 am. so trucks won't disrupt traffic, and even then only a couple of trucks at a time can fit in the closed lane on 29th Street.

Sutter tries to warn neighbors at least a week in advance when it has to close a street. Maas jokes that restaurateur Biba Caggiano still hugs him, so Sutter must be minimizing the problems.

Upgrading on the fly is "a giant, three-dimensional tic-tac-toe building," Maas said. For example, the hospital pharmacy was moved into a basement parking garage to make room for a new pediatric intensive care unit. The first couple of departmental moves were small and thus relatively easy. A large nursing unit needs to leave Sutter General room to make room for a connecting walkway.

To make sure none of the medical units gets an unwelcome surprise, none of the subcontractors can start any work without first telling Sutter what they want to do, when and why.

If the noise or vibration from construction is more than a physician or patient can handle, "it only takes one phone call to stop it immediately," Maas said.

Sutter General is relatively modern, built in the 1980s. But the original drawings don't always exactly match the structure when workers open up a wall. And the Office of Statewide Health Planning and Development says that if its staff can shine a flashlight on any part of a structure, the hospital has to bring it up to current code, Maas said.

The new women's and children's wing should cause fewer problems of that sort for future workers. The design uses Building Information Modeling, where all the components are "assembled" in a computer before the work is done in real life. If ductwork clashes with a support beam, the problem can be ironed out in the design stage rather than on the job site.

Profile – Sutter Midtown Construction

The Boldt Co. takes over $724M project midstream, finds new ways of creating efficiencies

The hard hats were nervous.

The team building Sutter Health’s monumental Women’s and Children’s Center in midtown Sacramento told concrete workers they were going to be videotaped and evaluated for inefficiency, something largely unheard of the industry.

"We sat down with them and the response was, 'You wanna do what?'" said Larry Maas, assistant administrator for Sutter's $724 million midtown Master Plan project.

It was just one of many unprecedented moves by general contractor The Boldt Co., which was brought onto the project in 2009 to right a ship that, if not sinking, was listing heavily.

The first thing Boldt did was shut down the project for a few months. Construction had been outpacing architectural drawings and the team was butting heads with state regulators, according to several people now working on the project.

Once construction resumed, Boldt started rewarding creativity and seeking to increase productivity, even if the methods hadn't been tried before. That included "dry runs" of construction techniques to root out inefficiency. Recording video of the structure's first concrete pour was one of those dry runs - and the effort revealed that the concrete hose would often snag on various metal structures. That would slow down the job as workers attempted to free the hose.

"If they have to do that 50 times, it adds up," said Michael Lehman, one of the chief architects on the project.

Besides correcting the concrete hose hang-ups, Boldt developed an alternative to a costly idea of filling in an atrium at Sutter General Hospital and built a life-sized mock-up of another medical area in a warehouse to test its viability. The company gives out innovation emblems to workers, kind of like those awards adorning helmets of college football players. And that videotaping? That’s like watching game tape.

Maas said the concrete company that was initially apprehensive about it has since embraced the idea, saying it will provide a competitive advantage when it bids for future jobs.

So it's anything but business as usual for Boldt, based in Appleton, Wis., which can trace its roots back to the late 19^th century.

"In our industry, productivity lags far behind," said Jay Harris, Boldt's vice president for Northern California. He said the industry average is about 50 percent productivity, meaning workers are idle about half the time because of some conflict. It's a standard that has actually declined over the past 50 years, Harris said.

With 289 workers on the Sutter job and an expected 550 at peak, productivity gains can have a big impact.

Boldt has been on a mission to make it happen.

The company came to Sacramento three years ago specifically to work with Sutter after successful collaborations elsewhere in California.

In July 2009, Boldt replaced Turner co. on the midtown project—which is actually four searate projects. The portions still being built are a complete renovation of Sutter General Hospital while it remains functioning and the Anderson Lucchetti Women's and Children's Center, the structure visible from the Capital City Freeway, That project is expected to wrap by 2013.

"It's not a decision you make lightly," Maas said of switching contractors, but he said it was one that needed to happen, There was a strained relationship with state regulators at the Office of Statewide Health Planning and Development and that needed to be repaired.

And much of the scheduling and process of building the projects was rethought.

Boldt is one of several construction companies that have sought to fight inefficiency with new techniques. Specifically it has been researching what's known as lean construction and integrated project delivery. These efforts are still somewhat in their infancy industry-wide, Harris explained, but are constantly being studied.

Lean techniques borrow from the manufacturing industry, which has made great strides in eliminating waste in the production process. Some refer to it as "The Toyota Way" after that company's philosophy of continuous improvement. Integrated project delivery, meanwhile, is all about collaboration and tapping into the expertise of everyone on the job.

Part of the process is empowering onsite managers to make decisions, Harris said, such as deciding to spend an extra $10,000 to solve a problem versus shutting down the project for a length of time.

So the most important thing was changing the culture and getting workers engaged again.

"It's always a challenge to identify what the issues are and correcting those issues," Harris said. "There was a negative stigma about this project. In this case we needed to get the momentum back. These guys like to do what they're doing and morale is up."

Profile – Sutter Midtown Architects

Project leaders thrive on trust to work with state, medical group

Lionakis and EwingCole, two architecture firms well versed in health care design, are experiencing something new with Sutter Health’s massive, $724 million midtown project. Principals from the two companies are part of a core team of managers that meets weekly in no-holds-barred bull sessions where feelings—and blame—are left at the door.

The key players involved say the arrangement has opened their eyes to a new way of building.

"Once in a career do you get an opportunity like this," said Don McAllister, a principal from Lionakis. "We view the project as a company and the core team is like management."

That makes everyone responsible for its success or failure. The team consists of two architects, two Sutter administrators and two leaders from the general contractor, the Boldt Co.

"The system works only if the partners trust each other," added Michael Lehman, who directs the West Coast health care practice for design firm EwingCole of Irvine. "That means you have to have reliable promises—you can’t promise something if you don’t understand what it takes to fulfill it."

Lehman said the owners of other projects have strived for such trust, but it’s extremely rare to see it put into practice.

PICKING UP THE PIECES
Both firms were brought onto the project midstream after problems developed under the previous team. Those problems stemmed from the team's relationship with the Office of Statewide Health Planning and Development, a regulatory body that closely scrutinizes health care projects and makes sure the state's new hospitals are safe. As the team's relationship with OSHPD grew more contentious, the project nearly was shut down by the agency.

Larry Maas, assistant administrator in charge of the project, said that relationship has improved since the collaboration between the health system, architects and builder was established.

McAllister and Lehman are longtime health care designers, both having worked in the field since the mid 1980s. Both have experience entering projects after they already are under way. The lessons they learned: Forget the history and don't blame the predecessor, but look forward to overcoming the challenges.

ADJUSTING ON THE FLY
Lionakis is Sacramento's largest architecture firm, founded in 1909. It had 51 licensed staff in the Sacramento office last year, more than double its nearest competitor in the region. The company concentrates on the Western U.S. and works on a variety of civic, education and commercial buildings.

But health care projects are a major concentration for the firm as well. Its designs can be seen across the region, including Kaiser Permanente medical office buildings from Pointe West to Elk Grove and regional specialty clinics from several providers.

Within Sutter's midtown master plan, the company was brought in on the renovation of Sutter General Hospital. The trick with that project is that the hospital must remain functioning while the upgrades take place. As part of Sutter's midtown project, Lionakis also oversaw the completion of Sutter's new medical office and ambulatory care building.

EwingCole is a national firm founded 45 years ago with a wide range of expertise from building health care projects coast to coast. It was handed the Anderson Lucchetti Women's and Children's Center, the large steel-framed building that's a cornerstone of the Sutter project. The firm has completed more than 50 large health care projects in the US. in the last decade.

On the Sutter project, the architects had to do more than repair the relation· ship with OSHPD. They've done some redesign to cut costs without diminishing value, such as changing the types of interior finishes to ones that still meet the hospital's goals but are less expensive than those originally selected.

They sat down with trade contractors and asked for their input on the best way to do the job, such as which light fixtures do they prefer to work with and how they can most efficiently accomplish tasks. The job of building information modeling, which is a three-dimension rendering of the entire structure that's normally the purview of designers, was given to the framing contractor.

The project has had to adjust on the fly, they said.

Maas noted that an atrium at Sutter General was originally supposed to be filled in to create more room for surgery space. But that meant shutting down wings of the hospital when material would need to be brought in by cranes above the structure because it's too risky to keep patients in areas that could be damaged by falling debris. After several attempts by contractor Boldt to convince hospital administrators otherwise, an alternative was found.

Both said the experience will have a major impact.

Lehman said it will improve EwingCole's ability to respond to industry needs on a variety of projects such as pharmaceutical labs by aiming for a more integrated team and construction process that improves productivity.

Lionakis' workers have even formed book clubs to study how construction can become more efficient, McAllister said.

"It will change our company," he said of the Sutter project. ''We are thinking and operating differently."