Administration and Leadership, Communications & Dispatch, Equipment & Gear, Training

Planning for Expansion

Issue 9 and Volume 35.

The Montgomery County Hospital District (MCHD) has provided EMS services for more than 20 years. Headquartered in Conroe, Texas, a suburb north of Houston, MCHD is the primary health-care provider and critical emergency responder in Montgomery County—one of the fastest growing counties in the nation. The district has a service area of more than 1,100 square miles, a population of 450,000, and it responds to approximately 44,000 calls each year. 

For decades, MCHD didn’t operate out of fixed, permanent facilities. In 2010, the service opened its first two permanent, standalone, district-owned EMS stations. This article focuses on the decisions behind that change and outlines some important considerations for EMS services tasked with a similar project.

“It became clear to us that we had a great need for improved facilities. We needed more than just a paint job or better appliances in our stations,” says MCHD Chief Executive Officer Allen Johnson. “It was necessary to pause and review our long-term needs. We discovered that ultimately, we needed to construct new stations and be in complete ownership of our facilities.”

In 2008, MCHD’s board of directors authorized a comprehensive planning study to determine how to best meet this mission in the future. Prior to 2008, Montgomery County EMS operated out of trailers, re-purposed residential facilities and co-locations within municipal and rural fire departments. In order to support the expanding demands of the county’s population and to provide the personnel and equipment needed to carry out its mission, MCHD embarked on a revitalization of its facilities in fall 2008.

From the beginning, the district’s staff took full advantage of the opportunity to make improvements in a number of areas, including location, response times and operations efficiency. “We’re all about maximizing opportunities,” says Kelly Curry, chief operating officer. “We put a lot of effort into stretching every dollar, as well as innovative planning.”

Lessons Learned
The planning, design and construction process was foreign to staff members when they began the project. There was also a learning curve for contractors to build with the input of an EMS team. However, along the way, many lessons emerged from the planning, programming and construction of what has now become the future direction of MCHD.

Just as a layperson wouldn’t understand or know the significance and context of such health-care and EMS terms as “clinical trajectory” or “repetitive persistence,” the jargon of developing new facilities was initially foreign to MCHD staff members. Such terms as “construction contract procurement,” “schematic design,” “site pre-development activity” and “phased installations,” as well as distinctions between proposal methods, were better understood by MCHD’s operations staff.

With EMS station construction, location is important primarily in terms of accessibility and response times. It’s not necessary to pay top dollar for prime real estate; curb-front property isn’t essential. What is important is ease of community access. The bottom line is that it’s OK to be “off the beaten path.”

MCHD used demographic mapping software to identify historical call locations and volumes and to plot response time frames. After analyzing this data, appropriate areas within the county were pinpointed to receive new facilities.

When purchasing property for new MCHD stations, the site’s capacity to support space for radio tower construction was also considered because MCHD provides an 800 trunked radio system, which operates the broadcast radio towers for all public safety entities in the country. This maximizes usage of the property and provides the opportunity for additional revenue.

In accordance with the Texas Government Procurement Act, MCHD was required to issue and advertise for qualified architects, so district staff members developed a scoring system to fairly rank design consulting firms. Each construction firm was given identical packets with 19 questions, which were opened at a public meeting. MCHD staff members then input the data into a matrix, which was used for analysis and scoring of the candidates. Later that day, a recommendation was made to the board of directors with the supporting scoring tool.

Questions to potential contractors sought the following information: whether they were state licensed, how many years they had been in business, whether they had significant experience with public entities, and whether they had adequate resources and proof of insurance, as well as their level of competence. Examples of local work were also requested.

Building a Diverse Team
Having the right team of engineers, architects and health-care planners to brainstorm industry specifics is essential for forecasting potential issues. The team’s willingness to work through many ideas provided the most optimal results. However, if knowledgeable in-house expertise isn’t available, some organizations might find it beneficial to hire a construction administrator to help sort through the many available options.

“Sitting around our planning table with a large number of experts—each in their respective areas, I think this was key to our success,” says MCHD Project Coordinator Matt Folsom. “There are so many details that can fall through the cracks, and no one person can catch everything. A number of our in-house operations staff are also medics, so this helped us see things from their perspective. But if you don’t have this duality, you should consider inviting representatives from the field to serve on your planning committee. Their perspective is invaluable.”

One example of how this collaboration is beneficial involves the reality of working a 24-hour shift with someone. There must be enough “individual space” built into the design. Everyone needs breathing room, and in the high-stress jobs of EMS providers, this detail is essential. But it can easily be overlooked by those not in the field.

When working with a design team, requesting step-by-step process explanations, much like that of an EMS responder’s explanation to a patient, was a crucial first step. Reciprocally, MCHD educated the design team about the district’s operations and systems, and even had members of the design team participate in ride-alongs. “The ride-alongs allowed my team and I to witness firsthand the dynamics of what takes place on a call, and to see MCHD’s professionalism and culture in action,” says Ian Powell, partner with PBK Architects. “That experience made this project much more than just another job for me.”

Just as the PBK team’s experience with the ride-along helped them understand the needs of EMS providers, MCHD’s staff learned about bidding for construction, schematic design, value engineering, building methods and the like. When constructing new stations, partnerships can also dramatically impact the final product, especially in terms of maximizing funding, sharing space and gaining community support. For example, MCHD partners with a local fire department to share a station footprint but occupies separate spaces, sharing only a common wall and having separate utilities and facilities (similar to a residential townhome).

In other examples, MCHD has designated a portion of one of its sites as a city park, and it shares another property with the school district’s police department. Creative partnering not only stretches funds, but it also fosters a sense of community, unity and common goals.

Planning with a Purpose
MCHD planned for a number of relatively low-cost “extras,” including a wellness room and climate-controlled storage. Wellness is high on the district’s list of priorities, and this is a low-cost way to help the EMS providers maximize their downtime.

The wellness rooms house a few pieces of exercise equipment, so crews can exercise during downtime. Another low-cost structural consideration is the inclusion of a climate-controlled storage area. MCHD’s stations are now designed to have the storage entry door in the ambulance bay, which provides more efficient access to medication that needs frequent restocking.

Technology can result in skyrocketing costs. MCHD is known for its innovative technology and aims to be on the cutting—but not bleeding—edge of technology. Following this school of thought can help in terms of reliability and the integration of systems. Technology is continually changing, so MCHD technology staffers decided to invest in the structural technology backbone necessary to grow as developments are made.

Smart planning efforts also include using prototype plans with the goal of reducing turnaround time from initial candidate site analysis to handing over the facility’s keys. “Of course, minor adjustments are part of the reality, but we stick to the same basic design in order to control costs and remain true to our time line,” says Folsom.

MCHD is in the process of constructing additional stations. An administration/service center, which will incorporate a new dispatch center, is currently under construction, and eight more stations are scheduled to be completed over the next five years. MCHD will continue to document its experiences in the hopes of sharing with others in the industry to make their construction processes easier. JEMS

Acknowledgement: Special thanks to Kelly Curry, LP, RN, and Matt Folsom, LP, who also contributed to this article.

Key Questions

  • Consider the following questions before proceeding with a building project, no matter what the size:
  • What works best for your organization: back-in or drive-through ambulance bays?
  • Do you plan to offer storage of emergency response vehicles other than the standard ambulance (vehicles from other organizations, mobile command vehicles or disaster trailers)?
  • Can all four doors of the ambulance be opened, and, at the same time, can you pull out the stretcher while the ambulance is in the bay (“vehicle-building ergonomics”)?
  • Where will you locate shore lines for vehicle charging in bays?
  • Should you consider including an auto-shutoff system for stoves?
  • Is your station alerting system well-thought-out?
  • If funds for generators aren’t available, are there at least generator hookups just in case?
  • Can you develop a service lease for a generator provider to have on-call generators for you when weather conditions are imminent?
  • How will the American with Disabilities Act (ADA) requirements affect your facility? They may not make sense to you, but if you’re a public entity, it’s a reality that can’t be changed locally. Some things must be accepted and accommodated.
  • What are the fire code requirements, specifically regarding sprinklers?
  • Do you want to consider creating a scaled-down “classroom” in major EMS stations for staff meetings, training, assessments, etc.?
  • Would a centralized (instead of distributed) emergency materials storage/deployment site(s) or central storage “barn” be more efficient for your operations?

Helpful Hints
Before starting a building project, it’s a good idea to do the following:

  • Become familiar with the specializations among design disciplines.
  • Discover the conventions and routine assumptions contained within the design and construction process.
  • Realize the range of services needed to study sites for optimum usage.
  • Incorporate site due diligence planning.
  • Consider disaster preparedness, specifically building resiliency
  • and survivability.
  • Determine the degree of redundant system planning that’s required and financially supportable.
  • Ensure the professionals and contractors are capable of successful installation of redundant systems.
  • Engage professionals for land acquisition, soils analysis and environmental analysis.
  • Strike a balance between efficient and effective value engineering decisions; and lastly,
  • Accept the pace and flow of the planning process as a challenge and opportunity.

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