Executive Summary 1 THE NEED 2 THE PLAN 3 THE DECISION REQUEST

Transcription

1 Executive Summary St. Paul s Hospital has a diverse and challenging mandate. It is a community hospital to the hundreds of thousands of people who live, work and visit Vancouver s downtown peninsula. 25% of inpatient days service clients form the beleaguered downtown east side but 44% come from outside of Vancouver, from across the province and beyond. St. Paul s is one of only two adult academic health science centers in the province training thousands of doctors, nurses, technicians and specialists annually and translating research from theory into practice. Its centres for Heart, Lung, Renal, HIV/AIDS, and Mental Health are recognized internationally for their quality and innovation. The hospital has been in its current location since 1894 and is proud of its heritage. But it is operating at capacity and its aging infrastructure will not allow it to keep pace with demand. It has absorbed 40 years of growth since its last planned addition with the master plan of % of its buildings are more than 50 years old. Even the newest Providence buildings constructed in the 1970 s and 80 s are only half sprinklered, the operating rooms are half the size of today s standard, and building systems are at the end of their expected life. The heritage Burrard building, that houses the emergency department, has virtually no ability to withstand even a moderate earthquake. Not that long ago ambulatory care was a small component of the hospital s work. Today St. Paul s operates 86 outpatient clinics and services in 19 different locations around the campus seeing over 267,000 patient visits last year. Those volumes are projected to increase by almost 25% in 2020 and 50% by St. Paul s has 435 funded inpatient beds but 40% of them are in 4-bed rooms (including those in the Critical Care units) and secured mental health units are located in buildings dating back to Projections indicate that the hospital will need 30 more beds by 2020 and 29 more by The emergency department is operating at capacity seeing over 73,000 patients annually. For the past 5 years the average annual increase has been almost 5% and and volumes are projected to increase to more than 81,000 cases by 2020 and 90,000 cases by Since 2000 St. Paul s has tried to liberate space for care by relocating non-clinical staff away from the hospital campus. Strict space policies promoting efficient open office environments and controlling entitlement have been implemented but still there is not enough room for patients. With redevelopment, St. Paul s will have the infrastructure it needs to meet demand and create a sustainable environment for health care. It will emphasize the patient as a partner, staff collaboration, efficient work flows, flexible space, and modern technologies. 1

2 The redevelopment plan has five components: 1A Preparatory Projects The obsolete Comox building and Power House will be decanted and demolished to create a building site for new construction. 1B Ambulatory Care Building A new building will house most of the hospital s outpatient services with interventional suites (including operating and procedure rooms), centres for rehabilitation and infusion/transfusion/ dialysis, as well as specialty clinics. 2 Providence Building Infrastructure Upgrade Upgrades to the structural (seismic), electrical, mechanical and information technology infrastructure of the sound but dated (circa ) building, will extend its useful life another 40 years. 3 Providence Building Renovations Once the ambulatory care services have been relocated to the new building, the Providence building can be renovated to improve and expand inpatient units including critical care, laboratory, diagnostic imaging, pharmacy, surgical suite and logistics services. 4 Burrard Building Infrastructure Upgrade The Burrard building is at severe risk of failure in an earthquake and some electrical/ mechanical systems date from the original construction (circa ). Seismic and service upgrades will ensure its continued usefulness. 5 Burrard Building Renovations Once outpatient services are relocated to the new ambulatory care building and inpatient services are relocated to the Providence building, the historic Burrard building will be repurposed for administration, research and teaching. 2

3 Estimated Funding The project would be funded through a variety of sources: ProvincE P3 debt (50% of P3 contract) $ 133 million Restricted Capital Grants (RCG) $ 607 million Project Reserve $ 40 million $ 780 million providence health care society $ 30 million st. paul s hospital foundation $ 40 million $ 850 million PHC will contribute land for the new ambulatory care building assessed at $47 million. Its monetary contribution of $30 million will be raised through leverage of other land assets. To meet its funding commitment the St. Paul s Hospital Foundation has prepared a capital campaign to be launched on government approval of the concept plan. Implementation Time Frame The project will take 10 years to complete beginning with the preparatory projects, followed by construction of the new ambulatory care building and infrastructure upgrades to existing buildings targeted for completion by Renovations will advance in phases between 2018 and Decision Request Providence Health Care and Vancouver Coastal Health Authority request that: The Project Board accepts the St. Paul s Hospital Redevelopment Concept Plan dated September 2013 The Ministry of Health submits the Concept Plan to Government for consideration 3

4 1 THE NEED

5 1 the need 1.1 Meeting Demand VANCOUVER CITY CENTER- WEST END VANCOUVER CITY CENTER- OTHER VANCOUVER WEST SIDE VANCOUVER SOUTH 12 % 7 % 7 % 4 % VANCOUVER MIDTOWN VANCOUVER DOWNTOWN EASTSIDE 12 % ST. PAUL S INPATIENT VISITS BY PATIENT ORIGIN FISCAL YEAR 2011/ % 4 % 3 % 3 % VANCOUVER NORTHEAST NON-B.C. UNKNOWN ADDRESS (INCL. HOMELESS) REST OF B.C. 44 % Community, Regional and Provincial Mandates St. Paul s Hospital is an important resource to its immediate community, the region and the province of British Columbia. It is located in the heart of Vancouver s Downtown Peninsula, an area that includes the Central Business District; West End, Coal Harbour, Yaletown and False Creek North residential areas; as well as the Downtown East Side neighbourhoods of Oppenheimer, Strathcona, Thornton Park, Victory Square, Gastown and Chinatown. The City of Vancouver expects this area to be home to 100,000 residents and 173,000 employees by It is a vibrant, dynamic community with a growing need for health care. St. Paul s is operated by Providence Health Care (PHC), one of the largest Catholic health care organizations in Canada. PHC is a party to the Master Agreement between the Denominational Health Association and the Province, under which it can own health facilities and deliver health services. As an affiliate, PHC receives its operating and capital funding through Vancouver Coastal Health (VCH), including designated funding for provincial programs from the Provincial Health Services Authority (PHSA). St. Paul s provides a continuum of primary, secondary, tertiary and quaternary care totaling 20% of all acute health services in the Vancouver 5

6 Coastal Health region with 44% of inpatient volumes being from outside the city of Vancouver. The Cardiovascular Program is a leader in coronary intervention, heart surgery and electrophysiology. It is the province s sole provider of care in advanced heart failure and transplantation. 23% of all cardiac surgeries in BC are performed at St. Paul s and 43% of SPH cardiac surgery patients live outside of the Vancouver Coastal Health Region. St. Paul s Respiratory Program is a centre of excellence offering specialty clinics in Chronic Obstructive Pulmonary Disease (COPD), Asthma and Adult Cystic Fibrosis. The Renal Program serves 17% of British Columbians with chronic kidney disease. It provides kidney function clinics, haemodialysis, training for home peritoneal dialysis, and kidney transplantation. The HIV/AIDS and Addiction Program is the largest of its kind in Canada. The inpatient unit is the tertiary referral centre for HIV positive cases and provides 70% of the province s inpatient care for HIV/AIDS. The program distributes antiretroviral therapy throughout the province and monitors HIV related outcomes as part of the mandate of the BC Centre for Excellence in HIV/ AIDS. The Mental Health Program includes general inpatient, ambulatory and specialized services, and specific tertiary programs for eating disorders, reproductive mental health and chronic pain. The program focuses on inner city mental health and treatment of concurrent disorders (both a mental disorder and substance misuse) and sees 43% of the most severe mental health emergency patients from across Vancouver Coastal Health region. St. Paul s is the primary provider of care to the Downtown East Side where more than 10,000 people fulfill the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) criteria for harmful substance use. As many as 7,000 are injection drug users and many suffer from mental illness. The number of homeless people in downtown Vancouver is estimated at Together, these populations account for approximately 23% of total inpatient days at St. Paul s. 6

7 1.1.2 Academic & Research Mandate St. Paul s Hospital is an academic health science centre and as one of only two general adult teaching hospitals in the province, plays a vital role in the education and training of health professionals. In partnership with the University of British Columbia (UBC) Faculty of Medicine, St. Paul s provides hands-on experience for over 1000 undergraduate and post-graduate medical students each year and for some sub-specialties it is the only teaching site in the province. The St. Paul s Hospital s Family Practice Residency Program is the largest training program for general practitioners in the province. St. Paul s is also home to BC s International Medical Graduate Program and site for the clinical evaluation of foreign trained professionals. In addition the hospital placed over 2200 students in nursing, allied health and medical technology last year from a broad range of educational institutions. The Providence Health Care Research Institute (PHCRI) partners locally with academic centres within VCH and PHSA, and collaborates nationally and internationally. Last year it employed 655 full time equivalent staff and attracted more than $34.4 million in research awards Service Volume Projections Redevelopment of St. Paul s Hospital is predicated on need. The existing buildings were designed to meet health care needs anticipated by the master plan of 1972 and have absorbed 40 years of increased demand. The proposed redevelopment is planned to allow it to continue to fulfill its mandate based on patient care volumes projected to fiscal years 2020/21 and 2030/31. Current patient care volumes were identified through a variety of internal sources including Providence Health Care (PHC) finance, health information management (medical records), and administrative decision support. Projections were developed utilizing Canadian Institute for Health Information (CIHI) Discharge Abstract Data (DAD) and PEOPLE 36 population statistics for British Columbia. Population estimates and projections range from low to high. Data presented is the medium range and is considered to be the most appropriate. All projections have been reviewed and accepted by Providence Health Care, Vancouver Coastal Health, and the Ministry of Health (Health Authorities Division and the Performance Modeling Analysis and Reporting Branch). Demand is classified in three categories: inpatient services, the emergency department and outpatient services as follows: 7

8 Inpatient Services (Beds) FY 2011 FY 2020 FY 2030 Medical Surgical Critical CarE Maternity Neonatal Intensive CarE Mental Health Emergency Department FY 2011 FY 2020 FY 2030 Separations 72,824 81,196 90,775 Outpatient Service Visits FY 2011 FY 2020 FY 2030 Allied health 16,093 18,818 22,266 Physiotherapy & Occupational Therapy Cardiac (General Clinics) 30,374 35,986 44,012 Heart Transplant, PACH, Pacer, Heart Function Healthy Heart, Heart Rhythm (incl Afib & EP) Cardiac (Testing) 20,509 24,299 29,717 Holter, ECG, ETT Elder CarE 3,470 3,969 5,918 Family PracticE 0 20,000 22,399 (Primary Care Attachment) HIV/AIDS 23,411 25,127 26,660 (Immune Deficiency Clinic) Maternity 3,322 3,729 4,107 Maternal Fetal Medicine & Fetal Monitoring Clinics MedicinE 16,567 19,628 24,005 (General Clinics) Rapid Access, Respirology, Hemoglobinopathy, Home IV, Diabetes, Thyroid-Endocrinology 8

9 MedicinE 18,249 21,621 26,443 Medical Daycare (Infusions, Transfusions) Cystic Fibrosis Clinic Pulmonary Function Testing EEG, EMG Mental Health 21,704 23,796 26,010 Acute Psychiatric Assessment, Mental Health Outpatients, Chronic Pain, Eating Disorders Renal 28,300 33,528 41,009 Kidney Function + Integrated Care Peritoneal Dialysis, Hemodialysis Transplant and Vascular Access Clinics Surgery ClinicS 69,123 83, ,436 Ophthalmology, ENT, Audiology, Colorectal, Vascular, Neuro, Urology, Gynecology, Orthopedics, Rheumatology Surgical Interventions 16,082 19,397 23,600 Surgery Same Day, GI, Broncoscopy, Minor Procedures 267, , ,582 Diagnostic Imaging (DI) 77,454 90, ,162 Laboratory (phlebotomy) 116, , ,481 * note minor variations in totals due to rounding 461, ,310* 666,226* 9

10 In summary by 2020 St. Paul s Hospital expects to see increased demand over current activity of: Inpatient Services 6.9% 30 additional beds Outpatient Services 24.7% 66,061 additional visits Excluding DI and laboratory Emergency Department 11.5% 8,372 additional separations By 2030 demand over current volumes is projected to increase by: Inpatient ServicES 14% 59 additional beds Outpatient ServicES 48.9% 130,378 additional visits Excluding DI and laboratory Emergency Department 24.6% 17,951 additional separations This data and descriptions of the projection methodologies are presented in greater detail in Appendix 2 ST. PAUL S HOSPITAL - SERVICE VOLUMES & PROJECTIONS. 10

11 1.2 Infrastructure Renewal St. Paul s Hospital is old and over-crowded. It is a tight urban campus located on one city block in downtown Vancouver bounded by Burrard, Comox, and Thurlow streets and a lane. COMOX STREET 1946 COMOX BUILDING 1930 BURRARD WEST 1963 NORTH WING 1930 EMERGENCY 1986 THURLOW STREET PROVIDENCE BUILDING PHASE II 1988 POWER HOUSE 1912/ 1961 McDONALD BUILDING 1961 BURRARD BUILDING CENTRE BLOCK 1972 SOUTH WING 1939 BURRARD EAST 1949 BURRAND STREET PROVIDENCE BUILDING PHASE I 1979 ALLEY Existing Conditions Burrard Building constructed between 1912 and 1953 accommodates the emergency department; mental health inpatient units; various ambulatory care clinics; academic, research and administrative offices and support services. Comox Building constructed as a nurses residence in 1930 with an addition in 1946, houses a miscellany of administrative and research offices that cannot be accommodated elsewhere on campus. McDonald Building built in 1961 was renovated in the 1980 s for research laboratories. Providence Building, erected in 1979 and 1989, houses a range of diagnostic and treatment services including laboratory, pharmacy, medical imaging, surgery and interventional procedures; ambulatory care clinics; inpatient units; and support services such as physical plant and materiel management. The physical condition of St Paul s Hospital is deplorable. Multiple studies by independent consultants confirm that most of the buildings and services are at extreme risk of safety failure and shutdown. In 2003/04, the Ministry of Health commissioned VFA to audit the physical condition of all health care facilities in British Columbia. The resulting Facility Condition Assessment for 11

12 British Columbia Health Services assigned each building a Facility Condition Index (FCI), which is updated periodically. The provincial target, based on industry standards is a FCI of 0.10 or less. At St. Paul s, only the Providence II building meets this standard, the FCI of the Burrard building is extremely high at 0.44 and the Comox building at 0.88 is one of the worst in the province. The Province advanced funding for two upgrade projects in A major electrical project to replace the main switch gear, transformers and emergency generators in the Providence building is nearing completion. An elevator upgrade project is also underway, but there remains much to be done. There is significant concern over the structural/ seismic integrity of the buildings. The Providence building meets approximately 60-70% of the current post-disaster standard but the Burrard building, which houses the Emergency Department, has little ability to withstand even a moderate earthquake. In addition to the physical state of the buildings, their spatial configuration is an issue. Many spaces are just too small to meet current demand. 40% of all inpatient beds are in 4-bed rooms, including those in critical care areas and the configuration of staff and support areas is obsolete. Corridors are filled with equipment, and patient amenity areas are practically nonexistent. The hospital s secure mental health units are located in buildings dating back a hundred years, with no access to any exterior space. Outpatient services are scattered across the campus with 86 ambulatory clinics and services currently provided in 19 locations leading to staff inefficiency and patient confusion. In the surgical suite two operating rooms have been renovated to accommodate minimally invasive surgical equipment, but the other 12 rooms are vastly undersized (35 m2 compared recommendations up to 84m2). Also the preoperative and postoperative space is inadequate with a ratio of 1 bay per OR compared to the recommended minimum of 3 bays per OR. The emergency department at St. Paul s is operating at capacity with 49 treatment areas in its compact layout. This number is at the low end of benchmark standards for current volumes. St. Paul s has attempted to optimize the utilization of its current space. Since 2000, nonclinical functions have been migrated off-site and in 2010 a rigorous space policy was implemented to reduce the footprint of administrative space through the use of open office environments and rationalize entitlements. More recently, new or expanding ambulatory care clinics have had to be located off site in leased space. However, it is becoming increasingly difficult to identify individuals or groups who can be relocated from the hospital without excessively compromising operational efficiency or patient care. For detailed evaluations of the spatial and condition shortcomings of the existing buildings and services refer to the MASTER PLAN FOR PROVIDENCE AND BURRARD BUILDINGS whose Executive Summary forms APPENDIX 3 to this Concept Plan. 12

13 1.2.2 Strategies for new Construction & Renovation In developing the Master Plan for the campus, the Clinical Services Plan and detailed Functional Program for Ambulatory Care, it became clear the St. Paul s Redevelopment project must: Consolidate acute bed capacity for improved patient experience, safety and efficiency This requires both removing outpatient services from inpatient areas (reducing traffic through these areas) and repatriating mental health beds to the Providence Building where all other inpatient services are located. Optimize ambulatory care delivery and space utilization in a new building The ultimate goal is to improve the quality, access and safety of patient care delivered at St. Paul s. LEAN design principles, simulation modeling, physical mock-ups of standard rooms, and through-put analysis were all used to determine the right size, right number and right flow for patients, staff and materials co-located in a new building. Pursue environmental stewardship Building solutions will incorporate LEED Gold level and BC s Wood First features among other strategies to reduce energy consumption, promote carbon neutrality, and manage waste. While exploring the opportunities offered by a purposefully designed ambulatory care environment St. Paul s clinical staff identified a short-list of important concepts to guide the design of the building: Patient-at-the-centre Where services come to the patient Self-directed patient education Online, audio/video, printed materials, all easily available Group visits Care and education with several patients Common provider areas Flexible, multi-disciplinary areas to support the care team in an environment of collaboration Way-finding Simple, intuitive, direct Electronic patient record Complete, sharable, secure, digital health record for every patient Central registration Patients can self-register or be registered into a central system Central scheduling A highly accessible, single system for booking services Electronic communication Linking healthcare professional and patients through voice, text, and telemedicine E- Service patient reminders Automatic appointment or other reminders For greater detail refer to APPENDIX 3 AMBULATORY CLINICAL SERVICE PLAN. 13

14 1.3 Sustainable Healthcare The St. Paul s Hospital Redevelopment will facilitate implementation of important strategies to improve healthcare delivery Setting Standards for Ambulatory Care Development of a new ambulatory care environment offers many opportunities to: Link unattached patients to primary care providers This driver focuses on the local need for increased attachment to family physicians for our at-risk, severely addicted and mentally-ill downtown Vancouver population. It is also a key strategy for decreasing over-use of the Emergency Department. A primary care clinic as part of the ambulatory care centre would align with the General Practitioner Services Committee s Attachment Initiative to provide training opportunities for GPs and medical students generally and for serving marginalized populations in particular. Decreased inpatient bed utilization will be another potential benefit. A study by the Ministry of Health in BC studied patterns of hospital use by Richmond residents. The study found that when a patient had a family physician (as the most responsible care provider) there was a significantly reduced risk of hospitalization. In addition, about 21% excess hospital bed days were used by people without a primary care physician. Develop models for coordinated care especially around chronic disease management The aim here is to design patient care and flow models from a patient perspective, improving coordination of care amongst disciplines and various specialties and programs, reducing the number of patient visits, and improving the engagement of patients and families in their care. Chronic disease, including mental health, affects about 34% of BC s population but consumes 80% of the combined physician payment, Pharmacare and acute care budgets. PHC s leadership in chronic disease management (at the MoHS/ BCMA Shared Care Committee) is actively building partnerships between family physicians and specialists and will be foundational for this redesign. 14

15 Develop inter-professional care teams to support coordinated care Inter-professional care is the provision of comprehensive health services to individuals by multiple Health Care Professionals who work collaboratively to deliver quality care within and across settings. The team may include Registered Nurses, Nurse Practitioners, Dieticians, Therapists, Social Workers, General Practitioners, Specialists and others. In this model of care, all health professionals work to their full scope of practice allowing them to focus on care within their realm of expertise. Improved collaboration and teamwork assist in managing workloads, reduce wait times, and improve the quality of care. The benefits to the patient are significant including timely access to a variety of health professionals (during one visit) who can assist with preventative care, and/or treat a specific illness or condition. Strengthened partnerships between specialists, family physicians and other providers The Rapid Access to Consultative Expertise program which now offers consultation services in a number of subspecialties for family physicians across BC reflects the continuing evolution of an earlier model for cardiology consults at St. Paul s. The model supports the management of the patient with chronic disease by the family physician, which releases valuable specialist clinic capacity to reduce waitlists, provides immediate consultation, and minimizes patient travel. 15

16 1.3.2 Research, Innovation and Educating Tomorrow s Care Team Given the workforce shortages that BC faces, developing, recruiting, retaining, and making the most effective use of our health care professionals has never been more important. Academic health science centres play an essential role in developing a well-educated workforce that can compete on a global scale in attracting talent. The training of sub-specialists can only take place in academic centres. The redevelopment of the ambulatory care environment and the key resources such as the operating rooms, as well as enabling access to research space, are essential to attracting and retaining the best and the brightest clinicians and scientists. A robust and high profile clinical research environment at St. Paul s Hospital, including significant clinical trials activity, is key to attracting the next generation of world-class physicians and researchers to British Columbia, and to achieving the economic and patient care benefits of BC-based clinical research. There is strong evidence that patients who are treated at institutions with active clinical research programs have better health outcomes than those who treated at institutions that do not. The Canadian Institute of Health Research defines knowledge translation as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. The key success factor for this process is bringing together both the researchers and those who use the knowledge to provide care. Health services research is a multidisciplinary scientific field that examines how people get access to health care practitioners and services, how much care costs, and what happens to patients as a result of this care. Often the clinical results of clinical trials lead to consideration of adding new therapies to routine clinical practice. There is then the central question in Canada s publicly funded universal health care system: how much will this cost and what are the benefits? The ambulatory centre will be a hub of innovation, where clinicians work side-by-side with researchers, enabling continuous transfer of knowledge into care solutions. This approach will also enhance opportunities to engage patients as partners in planning their care, as well as identifying possible participants for research studies. The large number of ambulatory care patients in a coordinated care environment presents an opportunity to develop patient registries to collect data and support the development of new knowledge in support of big data (enormous accessible databases) and biobanking of clinical samples for future study. 16

17 2 THE PLAN

18 2 T H E P L A N 2.1 The Project Scope and Phasing The St. Paul s Hospital Redevelopment Project is divided into 5 components: 1A Preparatory projects 1B New ambulatory care building 2 Providence building infrastructure upgrades 3 Providence building Renovations 4 Burrard building infrastructure upgrades 5 Burrard building Renovations Preparatory Projects The St. Paul s Hospital campus is a dense urban site constrained on one city block in the downtown core. The land is owned by Providence Health Care Society. The purchase of additional land is cost prohibitive and would only be viable if contiguous with the existing property and no such property is or can be made available. The logical solution to the hospital s need for a development site for a new building is to create one by demolishing two substandard, underutilized structures the Comox building and the Power House. This entails: Leasing Space Interim accommodation for displaced staff Decanting Staff and services relocated from Comox Building & Power House Decommissioning Residual mechanical & electrical services relocated from Power House Renovation Decanted/decommissioned services relocated to Burrard building Demolition Comox and Power House buildings Realignment Thurlow Street drop off and access to Providence Building 18

19 2.1.2 New Ambulatory Care Building Because of the enormous potential of ambulatory care services in developing sustainable healthcare strategies, construction of the new ambulatory care building is St. Paul s first clinical priority for redevelopment. It is also the most cost effective physical infrastructure in acute care. The new building will accommodate most of the outpatient services provided by St. Paul s Hospital and include: Support services materiel management, medical device reprocessing, equipment centre Lobby/public functions Preadmission Centre (supporting Surgery) and Diagnostic centre with phlebotomy, ECG and Holter monitoring supporting multiple programs Surgical suite (6 operating rooms with pre and post operative care) Interventional suite (6 gastrointestinal (endoscope) rooms, 1 bronchoscopy room, 2 minor procedure rooms, with pre and post procedure care) Outpatient clinics in: Cardiology/Cardiac Surgery Ear, Nose & Throat (ENT), Audiology, Ophthalmology Eldercare Family Medicine (with primary care attachment and Maternity) Mental Health Renal Respiratory Surgery Rehabilitation centre cardiovascular, pulmonary, physiotherapy, occupational therapy, gait & balance, and Activities of Daily Living (ADL) Dialysis centre hemodialysis and peritoneal dialysis Infusion centre transfusions and infusions serving multiple programs The overall area of the building is anticipated to be 27,723m2 with 14 storeys above grade and one below grade plus 3 floors of underground parking. (For further details refer to APPENDIX 5 FUNCTIONAL PROGRAM FOR AMBULATORY CARE SERVICES). 19

20 2.1.3 Providence Building Infrastructure Upgrades Infrastructure upgrades for the Providence building include: Seismic reinforcement Physical plant (main electrical and mechanical systems distribution) Information technology / communications rooms and main distribution (For further details refer to APPENDIX 3 MASTER PLAN FOR EXISTING BUILDINGS) Providence Building Renovations Space left vacant by the relocation of outpatient services from the Providence building will be renovated to address existing deficiencies including those in: Clinical support pharmacy, laboratory, radiology, morgue, nuclear medicine, cardiac testing Critical care Inpatient units Materiel management loading dock expansion, laundry marshalling Public amenities dining room, sacred spaces Surgical suite operating rooms, post anesthetic recovery The business case for the Providence Building renovations will also investigate the feasibility of relocating the Emergency Department to the Providence Building versus renovating in the Burrard Building. (For further details refer to APPENDIX 3 MASTER PLAN FOR EXISTING BUILDINGS) 20

21 2.1.5 Burrard Building Infrastructure Upgrades Infrastructure upgrades for the Burrard building include: Seismic reinforcement Physical plant main electrical and mechanical systems distribution Information technology / communications rooms and main distribution (For further details refer to APPENDIX 3 MASTER PLAN FOR EXISTING BUILDINGS) Burrard Building Renovations Space left vacant by the relocation of outpatient services from the Burrard building to the new ambulatory care building and inpatient services to the Providence building and will be renovated to address existing deficiencies notably: Entry Emergency Department Support services Administration, research, and education (For further details refer to APPENDIX 3 MASTER PLAN FOR EXISTING BUILDINGS) 21

22 2.1.7 Business plan Development The components of the redevelopment project would be developed in greater detail in PHC/VCH approved business plans with completion dates corresponding to the proposed sequence of the work: march 2014 march 2014 December 2014 December 2016 December 2014 December 2018 Preparatory Projects ambulatory Care Building Providence Infrastructure Upgrades Providence Building Renovations Burrard Infrastructure Upgrades Burrard Renovations *PHC/VCH approved There are two viable options to address the future needs of St. Paul s Hospital Emergency Department: Renovation in place Currently included in Concept Plan costing for Component 6 Burrard Building Renovations Renovation and relocation (within the existing Providence building) These options will be explored in detail in the business plan for Providence Building Renovations. 22

23 2.2 Estimated Capital Cost and Schedule Implementation Schedule The timeframe for implementation of the redevelopment project is 10 years with targeted completion dates of: 1a Preparatory ProjectS may B New Ambulatory Care Building jun Providence Building Infrastructure Upgrades Sep Providence Building RenovationS dec Burrard Building Infrastructure UpgradES mar Burrard Building RenovationS mar 2023 (For further details refer to APPENDIX 6 CAPITAL COST BY FUNDING SOURCE BY COMPONENT- PAGE 18) Estimated Capital Costs The St. Paul s Hospital Redevelopment Project is divided into 5 components with project costs estimated at: 1a Preparatory ProjectS $ 418 million 1b New Ambulatory Care Building 2 Providence Building Infrastructure Upgrades 83 3 Providence Building RenovationS Burrard Building Infrastructure Upgrades 45 5 Burrard Building RenovationS 95 $ 850 million (For further details refer to APPENDIX 6 CAPITAL COST BY FUNDING SOURCE BY COMPONENT) 23

24 Project costs include construction, equipment and soft costs. For the overall project these are estimated to be: New building design & construction including escalation (P3 project) - Transferred risk, financing fees, bid response, SPV, Interest Demolition, renovation, upgrades design/construction including escalation Interim lease associated with Comox building decanting Equipment Information Technology Project Management (5.7%) Insurance ($1 per 1000) Irrecoverable GST (83% rebate) Project Reserve (5%) $ 226 million 41 Million 353 Million 9 Million 100 Million 40 million 35 million 1 million 5 million 40 million $ 850 million Construction costs were estimated by Quantity Surveyors based on feasibility studies for the Preparatory Projects, the Master Plan reports for the Providence and Burrard buildings, Master Plan, and the detailed Functional Program for the new ambulatory care building. These costs will be updated during business plan phases as the scope of the work becomes more defined. 24

25 2.2.3 Estimated Capital Funding Funding will be required as follows: ProvincE P3 debt (50% of P3 contract) $ 133 million Restricted Capital Grants (RCG) $ 607 Project Reserve $ 40 $ 780 million providence health care society $ 30 million st. paul s hospital foundation $ 40 million $ 850 million Public Private Partnership (P3) debt is assumed to be 50% of the total P3 contract for the new ambulatory care building which is anticipated to be the only component suitable for P3 procurement. Providence Healthcare Society will provide land for the ambulatory care building assessed at $47 million. In addition, it will leverage other land assets to contribute $30 million in funding. This funding will apply to the Component 3 - Providence Building Renovations. The St. Paul s Hospital Foundation has committed to a capital campaign to provide an additional $40 million. This funding will apply to Component 1B New Ambulatory Care Building. 25

26 2.2.3 Estimated Capital cash flow Work may be advanced or delayed in response to funding availability. With a 10 year implementation horizon cash flow (in millions) would be: P3 Restricted Project Total PHC SPH Debt Capital Grant Reserve Debt Society Foundation Total 2014/15 $ - $ 16 $ - $ 16 $ - $ - $ / / / / / / / / / $ 133 $607 $ 40 $ 780 $30 $ 40 $ 850 For detailed calculations of project costs, funding and cash flows along with Quantity Surveyor reports, refer to APPENDIX 6: ST. PAUL S HOSPITAL REDEVELOPMENT - COST & FUNDING ANALYSIS. 26

27 2.2.3 Operating Cost and Funding Impact One of the complicating factors in providing a high level indication of the operating cost impact of the redevelopment is the long time needed for project implementation. The following chronicles anticipated changes over time The Comox building and Power House will be demolished but this will have little impact on overall hospital operating costs due to the current low level of maintenance and utility consumption. The cost of leased space is included as a capital cost and will not impact operating costs. The new ambulatory care building will be constructed but will not yet impact operating costs other than one time start-up costs for implementation of operational changes and purchase of minor equipment that cannot be capitalized. The estimated one time start up costs will range between $34 million to $51 million The new ambulatory care building will open and will be able to accommodate additional patient visits. No significant increase in operating budgets for hospital care, clinical support and administration is anticipated as none of the projected beds will be in operation upon initial opening of the new Ambulatory Care Building. There will however be increases in physician billings due to the increased number of patients seen. These are anticipated to have increased by 25% in 2020 over current levels. The greatest operating cost impact is associated with the long term P3 contract put in place to deliver, finance, maintain and operate the new building. Based upon the structure of recent British Columbia P3 projects and prorating for the size of the Ambulatory Care Building, the estimated range of the Annual Service Payment is between $25 million to $27 million. This number will be further validated during the Business Plan phase and Procurement Analysis. 2020/2021 The Providence building will be renovated and able to accommodate an additional 30 inpatient beds and 3 new operating rooms. These will have significant annual hospital operating cost impacts if approved. Physician billings through MSP will also increase by some 7% due to the increase in inpatient beds from the current 435 to 465 beds. 2030/2031 The Burrard building will have been renovated and staff repatriated from leased space. Any operating cost increases for the building should be offset by a reduction in leased space across PHC. A roof top addition may have been constructed to accommodate 29 more inpatient beds. Ongoing annual operating costs for the 59 new inpatient beds (494 beds vs. current 435 beds) in 2030/31 is estimated to range from $25 million to $27 million. Ongoing annual operating costs for the 27

28 projected increase in ambulatory clinic volumes in 2030/31 is estimated to range from $10 million to $12 million. Physician billings through MSP will increase due to increased patient volumes over 2020: 25% for ambulatory care services and 5% for inpatient services. Estimated increase in MSP billing costs to achieve the 2030 ambulatory volumes ranges from $14 million to $15 million. The overall operating costs will be multifaceted and will be considered in detail in subsequent business plans. 28

29 3 DECISION REQUEST

30 3 Decision Request The investment in St. Paul s Hospital Redevelopment will result in the potential for 59 new inpatient beds, the capacity for 17,000 additional emergency department visits and the opportunity to care for 130,000 additional outpatient visits. Renewal of the Providence and Burrard Building infrastructure will ensure their continued usefulness, and create a modern and sustainable environment for health care delivery. Providence Health Care and Vancouver Coastal Health Authority request that: the Project Board accepts the St. Paul s Hospital Redevelopment Concept Plan dated September 2013 the Ministry of Health submits the Concept Plan to Government for consideration 30