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Do No Harm: Adaptive reuse in healthcare construction

Scot Oliver, executive director of Idaho Smart Growth

Scot Oliver

Buildings that are designed and built well can be valuable long after their original intended use is over. More than just a collection of wood, stone, steel and glass, a good building has an intention of exceeding a basic utilitarian purpose. It aspires to make a design statement, to be of service, to be an active participant in the community. Good buildings exhibit a lot of pride—in the developer’s mission, or business, or himself. This extends to the pride of design and craftsmanship that makes a building valuable long after the source of the pride is gone.

Some of our favorite buildings have been adapted from other uses.

SQFT Oct 21 column blurbThe old Ada County Courthouse, once slated for demolition, housed the state Legislature for a few years and now serves magnificently as the Idaho Law Center. Railroad warehouses became the cool, eclectic shops and offices in 8th Street Marketplace, and attracted the BoDo development around it. Old hotels got new life as office, residential and retail uses in the Owyhee, Hoff and Idanha buildings. Downtown department stores have been converted, like the Alaska Building offices and Athlos Academy’s headquarters. The office where I write this was an opera house in the late 19th century; three blocks away a warehouse from that era now houses the opera.

Even some older industrial buildings were built to last. Often, these buildings don’t survive redevelopment, but their high-quality construction and design can lead to interesting reuse—local examples from the early 1900s include the Biomark office/manufacturing building, built as a coal-gasification plant; the Linen Building and Powerhouse event centers; and the Armory, undergoing rehabilitation for a new use.

Increasingly, however, commercial and industrial buildings are victims of the national trend toward disposability and quick profit. There’s a sameness in design, and construction methods and materials are quick and cheap. The owners expect a relatively short business life in that location and build accordingly. There’s no motivation to think about the neighborhood context and how the building will fit in it over time. Owners of big-box stores or factories don’t live in the neighborhood and usually don’t have the sense of pride or long-term vision to create lasting buildings that enrich their context.

Health care is a rapidly growing industry that needs new facilities as it grows. The single largest private employer in Idaho is the St. Luke’s Health System; three of Idaho’s 10 largest private employers are healthcare systems. Nationally, healthcare workers are projected to be the largest workforce by 2020.

Yet the way health care is delivered is constantly changing. Not that long ago, healthcare delivery often meant doctors making house calls. This was followed by a rapid increase in hospital treatment, with a corresponding proliferation of large auto-oriented factory-like hospitals. Trends are shifting again. Patients, payers and the courts are deciding that too much growth and consolidation in the healthcare industry is not healthy. Today, U.S. hospitals have one million beds with an average daily occupancy rate of 70 percent, a decline of nearly 39 percent since the 1980s. Inpatient use declined by 16.1 percent from 1999 to 2012. This is due in part to the push by payers for evidence-based outcomes rather than more procedures and hospitalization. Demand is changing, too, as people look for care in ambulatory centers in their communities, or opt for direct care in their homes. Home healthcare jobs are the nation’s fastest growing sector, expected to increase 70 percent between 2010 and 2020.

Facility design is changing as well. Patients and their families are showing a preference for care in small, friendly, personal spaces with access to daylight and the outdoors. This mirrors their residential and business preferences: places that are walkable and have a lively mix of uses. As patients develop a more retail-oriented approach to healthcare choices, providers are adaptively reusing retail and commercial spaces to be closer to the market. There are many instances of large systems like St. Luke’s and Saint Alphonsus as well as smaller “docs-in-a-box” taking advantage of this trend.

Kaiser Permanente, one of the nation’s largest healthcare systems, has been promoting green, smart-growth healthcare facility design for years. Recently they held the international Small Hospital, Big Ideas design competition to encourage new thinking about hospitals that provide patient-centered healing with a small environmental footprint and also reduce costs and improve community health. The winning concepts propose places that inspire human connection and collaboration, blur the boundaries between the community and the traditional hospital setting, provide direct access to daylight and nature and go beyond carbon neutrality to restore ecosystems and biodiversity.

We can’t predict what’s next in healthcare demand and delivery, but we can expect the trend away from large centralized facilities to continue. Healthcare providers will be challenged to repurpose outdated buildings; if they fail the community ultimately will be left with the task. If we’re lucky, we’ll have good designs to work with. One excellent example is Fort Boise, the first large development in the area. Fort Boise started in 1863 as a U.S. Army cavalry fort and operated for many years before it was adaptively repurposed as a healthcare complex for the Veterans Administration. It’s a great example of how good design and construction can be a lasting community asset.

Scot Oliver is executive director of Idaho Smart Growth, a statewide nonprofit that promotes community choices in land use, transportation and community development issues.



About Scot Oliver