Can emerging alternative delivery processes result in better hospital design?
May 16, 2023
May 16, 2023
Protecting design intent on Canada’s biggest hospital teaches us about P3s, new design approaches, and the value of user engagement
A version of this blog appeared as “Protecting design intent,” in Design Quarterly, Issue 18.
Through the power of the P3 (public-private partnership) model, Ontario has been delivering critical public infrastructure—like hospitals, highways, and transit facilities—for more than 25 years. The government adopted the P3 delivery model to transfer the financial and project risks with large public projects to the private sector. Like any delivery model, there are pros and cons to the delivery process. These include keeping design intent, infusing community involvement, creating space for innovative solutions to emerge, and achieving value with dollars spent. After two-plus decades of use, all participants in the P3 process have learned many lessons.
And continued improvement of those processes has inevitably led to an adjusted delivery model. The progressive delivery model (PDM) allows the design and bidding activities to take place in parallel rather than sequentially. It’s an exciting approach.
Typically, when we’re engaged as the planning, design, and conformance (PDC) consultant for P3 healthcare projects in Canada, we follow a set process. It involves creating an illustrative schematic design (ISD) and project specific output specifications. Builder/contractor teams bid on these. Proponent teams (comprised of a general contractor, architects, engineers, specialist consultants, financier, and sometimes building operator) examine every aspect of the design. They pull it apart and put it back together again, sometimes in newly proposed configurations, to formulate a bid for the client.
For a current project, The Peter Gilgan Mississauga Hospital (TPGMH), we are using a different model. As the PDC architect, we spent two years in user engagement and consultation with clinicians and doctors at the hospital, while engaging authorities such as the City of Mississauga. This extensive period of deep user and community engagement helped as we created the design for the new hospital. We want to preserve this influence on the design.
Halfway through our design for the new hospital, our client decided to implement the PDM, which is a relatively new procurement method. The PDM allows the client to go to the market with a request for proposal while the PDC team is developing an illustrative schematic design and project specifications. This way, the client can release drawings with a clear design direction, which the competing teams of builders can use to generate a price and schedule for their bid.
We continue our design in the background side-by-side with the competition as opposed to the linear process where we would have finished our design before the RFP period in a traditional P3. The purpose of the RFP in the new progressive delivery model is to pick one proponent rather than three that you typically have in a design-build-finance or design-build-finance-manage P3 models.
Once the RFP has closed, the designer works with the winner, the first negotiated proponent (FNP). The FNP brings forward opportunities to find value, improve constructability, and save time and money. But in this collaborative model the teams work together. The PDC still supports the client side and is there to protect design intent and client vision. The FNP is looking for opportunities to drive additional innovation and best value for money.
The goal of this progressive model is to get the best of both worlds from the design and construction process. The model spurs collaboration. It gives the PDC team an opportunity to preserve the innovative elements and stakeholder needs integrated into the design, while giving the builders the incentive to keep the project on budget and schedule.
The overlap of the RFP open period with the ISD phase gives the team access to valuable constructability and procurement feedback early in the design phase. While no model is perfect, the PDM is proving to be a beneficial procurement model for Trillium Health Partners’ (THP) new hospital. It has shortened the project schedule.
The progressive delivery model (PDM) allows the design and bidding activities to take place in parallel rather than sequentially.
Another aspect of The Peter Gilgan Mississauga Hospital project made it not business as usual. Our clients—Infrastructure Ontario and THP—supported an “exemplar” design for most of the departments and site planning. This helps preserve the influence of user engagement and maintain forward momentum for the project. When we begin to collaborate with the builder group and their consultant team, they will be starting their work with the design developed by the PDC team, rather than unraveling it and starting over. The goal is to protect the client’s design priorities, and the user engagement and community input we’ve already designed into the project. This new approach helps drive increased levels of flexibility, digital enablement, health and wellness, and inclusiveness as part of a whole hospital design.
Ideally, this collaborative process protects the design intent and user input. It should result in a better, truer design. Reengagement isn’t necessary, which should save the client time and money. The big payoff is that it should result in a built environment that is a better fit for the community. By advancing the project with a design exemplar and setting the stage for a collaborative approach, we can avoid some of the pitfalls of prior P3 models where cost could trump critical design criteria. The optimal result will be a hospital that looks good, functions well, and is delivered within the client’s design and construction budgets. A hospital should be a place for healing. The spaces need to be a dignified place for the people receiving treatment and for hospital staff. This PDM model enables us to deliver elevated design while making effective use of public dollars.
TPGMH will be the largest hospital in Canada. It is a historical redevelopment and full replacement of the existing hospital. THP’s plan is to build an interconnected system of care to meet the health needs of its growing and diverse community for the decades ahead.
The new facility will be almost triple the size of the current hospital. It includes 23 stories, around 2.7 million square feet of space, and 950 inpatient beds. TPGMH will increase operating room capacity by 40 percent and feature the largest emergency department in Ontario, with the goal of lowering wait times and improving patient outcomes.
The new TPGMH will be an urban landmark and community hub reflecting the area’s multicultural and vibrant nature. It connects with the surrounding communities and is located along one of the city’s busiest streets, which connects Mississauga’s waterfront with downtown and three major highways. The hospital connects to the ground plane and the landscaping and pedestrian approach to the building and public realm.
The challenge for our team at TPGMH was designing a new vertical hospital on a sliver of land. And it must be built without disrupting the existing hospital, which needs to stay open until the new facility is ready.