HREI Project Case Study (July 2006

A study in gaining neighborhood support



Note: Much of the information contained in this article came from an informational session during the 2006 International Conference and Exhibition on Health Facility Planning, Design and Construction (PDC). PDC, which was held in late February in San Diego, is sponsored each year by the American Society for Healthcare Engineering (ASHE), the American Hospital Association (AHA), and the American Institute of Architects Academy of Architecture for Healthcare (AIA/AAH). The session was titled, “New Visions for New Hospitals” and entailed an in-depth look at the planning for the University of California San Francisco (UCSF) Medical Center’s quest to build a new hospital campus, starting with a children’s hospital, in the Mission Bay redevelopment area of San Francisco.

By John Mugford

Anytime a hospital plans a new development, be it a smallish expansion or a full-blown new hospital, it’s going to face challenges both large and small.

Perhaps no system knows this better than the University of California San Francisco (UCSF) Medical Center, a San Francisco-based health system with academics and research as key parts of its mission.

For several years now, UCSF officials have known that their system would eventually need to add new acute-care bed capacity to keep up with patient demand and to comply with California’s seismic safety regulations, formally known as Senate Bill 1953, by the 2013 deadline.

And while UCSF still has many hurdles to overcome before beginning a planned acute-care facility in the city, its process for overcoming one major obstacle – neighborhood opposition in a city of activists – is a study in how to get neighbors not only to accept its plans, but to champion them.

UCSF’s planning process for a future hospital in the Mission Bay area of San Francisco, including its numerous give-and-take sessions with neighbors, was presented in detail at the 2006 International Conference and Exhibition on Health Facility Planning, Design and Construction (PDC) in San Diego in late February.

Several professionals involved in planning UCSF’s future hospital campus shared information, strategies and anecdotes from the process. The presenters at the PDC session were Lori Yamauchi, Assistant Vice Chancellor of Campus Planning at UCSF Medical Center, and architects Jim Hall, Eric Meub and Simon Bruce from the San Francisco office of SmithGroup.

Where to build?

In addition to providing a variety of outpatient services, UCSF Medical Center is composed of two acute-care campuses in San Francisco: Parnassus Heights, with 526 beds in two hospital buildings; and Mt. Zion, which has about 60 beds for cancer surgery patients and provides a variety of outpatient services.

Because UCSF’s long-range goal is to have up to 650 beds in the city, system officials knew early on in the planning process that they would have to add a new facility in order to meet the goal.

They chose to build in Mission Bay, a redevelopment area near AT&T Park, home of the city’s Giants major league baseball team. Officials say a new facility is needed because UCSF’s two existing hospital campuses contain older buildings that would be nearly impossible to bring into compliance with Senate Bill 1953, which was enacted following the Northridge Earthquake in 1994.

For example, without making changes at Mt. Zion, the 60 beds there would need to be taken out of service by Dec. 31, 2012, according to Ms. Yamauchi. At Parnassus Heights, plans call for a reconstruction project that would remove about 150 beds in the older of two hospital buildings, leaving the campus with about 400 beds and enough space to implement longer-term solutions to the state seismic mandates.

Growth restrictions have long been in place at the Parnassus Heights campus, the result of pressure exerted by neighborhood groups – something quite common in San Francisco.

As if UCSF wasn’t already facing quite a few hurdles for its expansion plans, the academic medical center was looking to build a new facility in one of the toughest places in the country to do so: San Francisco, a densely packed landscape where a lack of available property has pushed land values through the roof.

Amid this backdrop, UCSF decided to eventually build a new acute-care facility on 14.3 acres in Mission Bay. Since the late 1990s, the university has been developing a 43-acre academic research and biotech campus in Mission Bay that’s home to a variety of tenants and institutions. Eventually, the research campus could contain a total of 2.6 million square feet of space. About 1.3 million square feet has been developed so far.

UCSF’s research campus is part of an overall, 303-acre redevelopment project started and master planned by San Francisco-based Catellus Development Corp., a real estate firm that was spun off from the real estate holdings of the Santa Fe and Southern Pacific railroads. In late 2005, Catellus was merged into Denver-based ProLogis (NYSE: PLD), creating the world’s largest industrial real estate development trust (REIT).

The redevelopment area includes new housing, retail, general office, public transportation, restaurants and other uses, such as a recently opened Irish pub. At one point, Catellus donated 30 acres of the 43-acre research campus, with the city of San Francisco donating the remaining 13 acres.

UCSF plans to develop its new Mission Bay hospital on land adjacent to the research campus, creating what administrators call “a bold new vision” for its acute-care, academic and research missions.

Children come first

Prior to the overall redevelopment plan, Mission Bay was, and still is, home to a variety of warehouses, industrial uses and buildings for shipping fleets. One area of Mission Bay is Dog Patch, an architecturally and historically significant neighborhood – one of the few to survive the 1906 San Francisco earthquake and fire.

During UCSF’s planning process with architects from the SmithGroup, plans varied greatly in size and scope. Early on, after architects and UCSF officials brainstormed with the provider’s various user groups, plans called for about 320 beds. When the planning team ran the numbers, however, the price tag approached a daunting, unattainable $2 billion.

As it turned out, UCSF estimated that it had about $700 million to spend at Mission Bay – it also plans to pump money into its Mt. Zion and Parnassus Heights campuses. The funding is coming from a variety of sources, including operations and a recently concluded, highly successful $1.667 billion philanthropic campaign.

Over the course of several months, the architects and UCSF’s leadership whittled the project down in scope. They also decided to build the Mission Bay hospital campus in phases over a period of years – most likely decades.

As it stands now, the first phase is likely to be a 180-bed children’s hospital with affiliated services, including outpatient surgery. At a later time, more facilities could be added in the areas of women’s health, cancer care and perhaps others.

“The overall integrated process we used was highly successful in that we got whole service lines to support common ideas and goals – there was clear consensus of where they were going and why,” said Mr. Bruce of the SmithGroup.

In retrospect, the planners told the PDC crowd, they would have placed more restrictions on stakeholders’ visions for the project from the outset, keeping it more in line with what the budget would allow, Mr. Hall said.

“When there is a disconnect between what people envision and what the budget allows, it can lead to dissatisfaction,” Mr. Hall said. “We did have to overcome that.”

Tenacious activists

Almost all architects, developers and hospitals looking to expand or build facilities have faced obstacles from their community, including neighborhood opposition. But perhaps nowhere in the country can activists be as daunting as in San Francisco.

Mr. Meub of SmithGroup told the PDC audience that San Francisco’s citizenry is considered among the most tenacious anywhere.

“The Mission Bay area is actually a mishmash of properties,” said Mr. Meub. “There’s plenty of quirky interface between condos and Victorian houses, and old, obsolete industrial uses.”

Those industrial uses include warehouses, gravel plants, maritime facilities and others.

“One would think this area is not a good candidate for preservationists’ concerns,” Mr. Meub added. “But this is San Francisco, where everything is entitled to be preserved. People who move into the area like the quirky nature of having Victorian homes next to gravel mix plants. And they want to see that maintained.”

When news hit the streets that UCSF was planning a new hospital, many neighbors became upset and emotional.

“One woman who’d lived in the area all of her life told us, ‘I can’t believe it, my neighborhood will be destroyed when you put in this huge hospital,’” Mr. Meub said.

One of the keys to overcoming such strong, emotional opposition, UCSF and SmithGroup representatives said, was to engage in plenty of meetings with neighborhood groups as well as the San Francisco Redevelopment Authority.

All meetings with neighbors were held right in Mission Bay – a small gesture perhaps, but an important touch in building a dialogue with opponents, the planners said.

“In projects like this, people have a sense of powerlessness and of distrust,” Ms. Yamauchi said. “And you have to treat those emotions with dignity. We tried very hard to do that, without compromising our goals and our vision.”

Another key to gaining support from the community is to identify and engage in conversations with influential voices of the public.

In UCSF’s case, one such group is the 40-member UCSF Community Advisory Group (CAG). CAG also includes smaller, more spread out “CAG Action Teams,” or CATs.

“CAG has 40 members of the public, both critics and supporters, from around San Francisco,” Ms. Yamauchi said. “They were instrumental in helping us build support and in informing us on how to work with the public in a transparent and collaborative way. At the same time, we’ve educated the CAG about our own needs and programs.”

Record neighborhood concerns

“One of our first steps was to gather the community’s concerns and record them,” Mr. Meub said. “We kept at this. This is a cynical group that wasn’t used to having their comments recorded. Doing this had a big impact and assured them that we took them seriously. We gained credibility doing that.”

Messrs. Meub and Hall also noted that the planning team made sure neighbors felt like they were a partner in the planning – which they actually were.

“And we want to stress that we asked for comments that constructively helped our process,” Mr. Meub said. “We said from the beginning that we did not want to hear comments such as, ‘Don’t ever build a hospital here,’ or ‘Over my dead body.’”

The emotional stories, according to Mr. Meub, included one from a man who had put $1.5 million into renovating his Potrero Hill home.

“The man told us, ‘Now you’re telling me my view of the Bay Bridge is going to be gone because a hospital will block my view,’” Mr. Meub said.

As a result of neighborhood input, designers and hospital executives decided not to build a tall hospital tower.

At one point, as discussions focused on the height of structures, UCSF planners and consultants showed the neighbors renderings of how tall new structures could be in Mission Bay – had UCSF decided not to build a hospital there.

“We showed them the maximum height, according to the guidelines, if some projects were built out to the envelope,” Mr. Meub said. “It might have been difficult to actually build that high because of some guidelines that have been a part of Mission Bay before UCSF got involved. But there was certainly a possibility that someone could build high enough to block views.”

While the UCSF presenters said specific heights have yet to be determined, Ms. Yamauchi added that the hospital will definitely be shorter and wider than what the area’s redevelopment plans would allow for other uses, such as office buildings.

“By redoing the design and throwing out the idea of a tower, it was a real sacrifice on UCSF’s part,” Mr. Meub said, “because it was a major reduction in capacity with about 100 beds taken out of the overall strategy.”

Lose capacity, gain bridge

However, compromising on height most likely gained UCSF the go-ahead for a pedestrian bridge that the system feels is an integral part of its future Mission Bay project. The bridge is needed, officials say, because a future street is planned through the heart of the campus, creating a barrier between the inpatient and outpatient facilities.

“San Francisco hates bridges over streets,” Mr. Meub explained. “People see them as obstructions to historic buildings, to the view. Other communities use them to great effect. But San Francisco does not. Even the redevelopment agency did not think this stood a chance to gain approval.

“But we developed, with the community as part of the process, a diagram of how it could work,” Mr. Meub said. “We laid the groundwork of listening to them and responding to them in a transparent way.”

Ms. Yamauchi added: “That bridge is vital not just to keep people from getting hit by cars but to connect acute and ambulatory care. It was important to make that connectivity because providing the ability to serve more patients in an ambulatory setting brings costs down for the overall project.”

“Ultimately, the neighbors became not only accepting of the bridge, but have championed it to other people and groups in the city. This was a huge win. We can’t say how vital getting that bridge was to making the whole vision happen.”

Still up in the air

The final chapter of UCSF’s Mission Bay campus is not written yet – including a specific plan and timeline. But after reducing its scope and gaining the support of neighbors, the project continues to take shape.

Latest estimates from UCSF Medical Center CEO Mark Laret indicate that the childrens’ hospital at Mission Bay could be about halfway complete by 2012. A final budget has not been determined.

Future components, such as women’s and cancer services, would be developed at a time when the system’s finances allow.

In the meantime, UCSF officials have said the system will likely add beds to its Mt. Zion campus to keep up with demand and to work toward complying with the state’s seismic requirements.q

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