NAVFAC has its own version of MX, although it is organized quite differently. For MX, there are two organizational entities – USACE project directors and a technical staff that includes architects and mechanical/electrical and fire protection engineers. Each USACE district and the private industry architects and engineers hired for each project are responsible for structural engineering, based on the regulations of the area in which construction is done.

“The function, size, and kinds of spaces needed for each facility are based on local area need, how much existing military capability they have, and what the private sector brings to bear. If it is a remote area, there might not be much local surgical capability, for example,” Marquardt said. “Most of the staff in my office have at least 25 years experience. My mechanical engineer is a noted expert in HVAC [heating, ventilation, and air conditioning], plumbing, lab construction, and isolation. My electrical engineer wrote most of the criteria we use in that area. My two fire protection engineers collectively bring about 50 years of experience.

“The function, size, and kinds of spaces needed for each facility are based on local area need, how much existing military capability they have, and what the private sector brings to bear. If it is a remote area, there might not be much local surgical capability, for example.”

“We’re not looking for entry-level people when we hire, but people from the Corps or other services, the VA, and private sector with healthcare experience. We also are responsible for writing the medical/technical unique criteria – not the size or use of a facility, but infection control issues, smoke control, sustainability, and functionality of elevators and communications and medical equipment. My engineers sit on a number of different associations and committees; that lets them stay up on the latest technologies and take experience and lessons learned from DoD projects back to those bodies.”

Since its inception, the MX has supported approximately 425 medical treatment or research facility projects totaling more than $8.2 billion, with a record of delivering projects on budget and on or ahead of schedule. Many facilities have been recognized with national design awards from the American Institute of Architects, Modern Healthcare Magazine, the secretaries of Defense, Air Force, and Army, and the Corps of Engineers.

Military hospitals tend to be smaller than major civilian facilities. Another difference in recent years has been the addition of adjacent warrior-in-transition projects for wounded warriors, including facilities for family counseling. Each facility includes components primarily, although not exclusively, for the treatment of those coming from downrange, such as a behavioral health unit, physical therapy, eye treatment, orthopedic care, and so on.

“A few years ago, I would have expected construction to slow down around FY 16 and move more to clinics. But that has dropped off more quickly and some proposals have been moved out to later in the decade,” Marquardt said.

“One of the trigger points was when Congress made a conscious effort a couple of years ago to push DoD to bring new projects online sooner than might otherwise have been the case. Which was good, because many of those had aged, and medical technology had advanced beyond what some of them could handle, even hospitals built in the 1990s.”

The MX currently is working on 11 hospitals or medical centers and nine major additions and alterations, some of which began in FY 08. All but four are now under construction, with Landstuhl and Fort Knox, Ky., under design, and construction just beginning at Fort Irwin, Calif., and Fort Bliss, he added. In each case, more than new medical technologies are involved – so are the latest in a series of advanced design processes.

“Originally, designs were done on paper, then we went to CAD [computer-aided design], then about 15 years ago to 3-D modeling. Then 10 years ago, with the advance of the Internet and improved technologies, we not only were able to design facilities in 3-D, but locate all the vertical and horizontal distribution patterns, communications, electrical service, water, HVAC, etc., in a Building Information Model [BIM] that allows us to see where conflicts exist and work out solutions,” Marquardt said.

“[The Office of the Assistant Secretary of Defense for] Health Affairs is doing some studies to ascertain that. I suspect the facilities will be smaller, partly as equipment such as MRIs [magnetic resonance imaging units] shrink in size. In just the past four years, we’ve seen a huge move toward all databases being tied together as part of the BIM process. I think there is movement afoot not to have as many or as large medical centers, but more small, remote centers

“We started doing that primarily in design, but with the Fort Belvoir project, a lot of what went into it was actually built off-site and, thanks to BIM, could fit into its slot. So the processes and planning are a lot more streamlined, with greater accuracy and quality assurance, which is needed, because our facilities have become much more complex. In the 1980s, when we were building Tripler [Army Medical Center, Hawaii], there was some confusion over the placement of a single computer. Now everything is controlled by computers and BIM has removed a lot of the opportunity for human error.”

Linking BIM to the Internet enables the builder to call up the attributes of materials and equipment much more accurately than before, directly from the manufacturer. BIM also provides the facility operator with component life expectancies and maintenance and monitoring requirements.

A plans and specifications process now turns field drawings into “living documents” that provide facility managers a good understanding of when equipment needs maintenance or replacement. What is now being learned will go into planning for the next generation of facilities in 10 or 20 years.

“[The Office of the Assistant Secretary of Defense for] Health Affairs is doing some studies to ascertain that. I suspect the facilities will be smaller, partly as equipment such as MRIs [magnetic resonance imaging units] shrink in size. In just the past four years, we’ve seen a huge move toward all databases being tied together as part of the BIM process. I think there is movement afoot not to have as many or as large medical centers, but more small, remote centers,” Marquardt concluded.

“Because our doctors and nurses have a contingency and operational mission, the need to have large medical centers with staff being trained beyond what small remote centers might allow is still part of the debate, however. One facility can’t do everything, so pieces of care that can be specialized in a support facility on a large campus are likely to become more common, along with more joint facilities. And more care will be delivered outside medical centers and in the home.

“It’s an imperfect science. We are the executioners, taking the need and the funded program that have been defined and building the facilities accordingly. A program design from Health Affairs is pretty specific regarding the number and types of ORs, beds, and other items. Our job is to ensure the structure and layout of the building handles those efficiently.”

In the more immediate future, Premo said USACE will continue working with the Office of the Assistant Secretary of Defense for Health Affairs to respond to future budget requests and defend the need for construction dollars to continue and complete ongoing projects.

“We really haven’t engaged in design for FY 15, although we are aware of several programs slated for that budget. My out-year look, then, really only goes to FY 15. We have lists of projects for FY 16 and 17, but really don’t know how the service restructuring will impact those. However, I expect we are looking at significant reductions in our workload through the next several years.”

“We also have another five projects scheduled to get under way in FY 14, for which we have about $600 million worth of work, but whether we get to pursue those is still being determined. We have eight projects in FY 13, three of which have been awarded at a total value of less than $300 million. Of the remaining projects, two may be impacted by the force reduction. It is up to the service components to make the final decisions,” he concluded.

“We really haven’t engaged in design for FY 15, although we are aware of several programs slated for that budget. My out-year look, then, really only goes to FY 15. We have lists of projects for FY 16 and 17, but really don’t know how the service restructuring will impact those. However, I expect we are looking at significant reductions in our workload through the next several years.”

This article first appeared in the The Year in Veterans Affairs & Military Medicine 2013-2014 Edition.