For both Orlando, Fla., and Las Vegas, Nev., a full-service VA Medical Center has been a long time coming – and within the year, the wait will be over.

Construction of the Las Vegas VA Medical Center is scheduled to be completed in late 2011, and when it opens its doors in early 2012, on a 150-acre campus at the southwest corner of the I-215 North Beltway and Pecos Road in North Las Vegas, it will offer a long-needed central location for primary care to veterans: a seven-story, 790,000-square-foot medical center housing a 90-bed inpatient care unit, a 20-bed mental health facility, and a 120-bed nursing care unit. The nursing care unit is architecturally tied to the medical center, a multi-tiered structure enclosed in a glass curtain wall and powered, in part, by an advanced photovoltaic system that capitalizes on southern Nevada’s most abundant energy resource.

In Orlando, the new VA Medical Center, a 1.2-million-square-foot, $665 million facility, will be only part of a new “Medical City” under development in East Orlando, a complex that will include the University of Central Florida Medical School, the Sanford-Burnham Institute for Medical Research, the Nemours Children’s Hospital, and the University of Florida Academic and Research Center. Set to open in late 2012, the Orlando VA Medical Center will increase access to medical care for about 400,000 Central Florida veterans. The LEED-certified silver facility, the first VA medical center built on a completely new “greenfield” site since 1995, will include a large multi-specialty outpatient clinic, 134 inpatient beds, a 120-bed community living center, and a 60-bed domiciliary.

The Orlando and Las Vegas medical centers are two of the most recent in a series of ambitious construction projects launched since 2004, when the Department of Veterans Affairs completed the early portion of its Capital Asset Realignment and Enhanced Services (CARES) study of VA Medical Centers nationwide.

“These are long-awaited projects,” said Bob Neary, acting director of the VA’s Office of Construction and Facilities Management. “We have six brand-new hospitals under way; four under construction right now. In Las Vegas and Orlando, two of the biggest and fastest-growing cities in the country, they have never had a VA hospital.”

The other new medical centers – in New Orleans, La.; Denver, Colo.; Omaha, Neb.; and Louisville, Ky. – are replacing decades-old facilities that no longer serve their surrounding populations as well as they should. In New Orleans, the need is especially urgent; the VA Medical Center on Perdido Street has been closed ever since Hurricane Katrina incapacitated much of it in August 2005. Since then, care for tens of thousands of veterans has been dispersed among seven clinics and an ambulatory care center, with some VA doctors providing inpatient care at other area hospitals.

Restoring a home base for a completely integrated health system for veterans, including inpatient care, long-term rehabilitation, and research, is an important step for New Orleans. The proposed 200-bed, $800 million medical center, set on 29 acres in the South Market District, will, like the Orlando VA Medical Center, be part of a larger medical district that will include the Louisiana State University Medical Center, the New Orleans BioInnovation Center, and the Louisiana Cancer Research Center. Construction on the VA Medical Center began in late 2010, and delivery of care is expected to begin in late 2014. Several features of the new hospital are noteworthy, including a heliport and boat dock for evacuations, and the location of all mission-critical service areas at least 20 feet above ground.

The New Orleans VA Medical Center represents another first for the VA: It’s the first time the VA has contracted a large project under something resembling the “construction manager at risk” delivery method, which establishes a maximum price early in negotiations. “As the design is going on, there’s a firm price negotiated with the contractor,” explained Neary. “Under federal acquisition regulations, that private-sector model gets a little tricky, so in New Orleans and in Denver, we held a competition with some of the early design drawings available, and firms had to come forward, demonstrate their qualifications, and then also provide us with what we call a ceiling price – they can’t go over that – and then a target price, the price they felt they could bring the project in for. So it’s our hope and expectation – and we believe it’s being borne out – that when they actually had to commit to a price, they knew more about the job, and therefore didn’t have to put in extra contingencies to guard against the unknown.”

The new Denver facility, Neary said, will replace the Denver Medical Center for the Eastern Colorado Health Care System, and is under construction on the system’s campus in the Denver suburb of Aurora. The 184-bed replacement center will include a 30-bed Spinal Cord Injury/Disease Center, a 30-bed community living center, and a research building.

Both the Louisville and Omaha centers are in earlier phases of development, Neary said. “Both those cities have VA Medical Centers, both constructed in the early 1950s, so they’re fairly old. In Omaha we’re in design now and we’ll be building the new hospital on the grounds of an existing hospital. In Louisville, we’re in the site selection process. We’re looking at five sites: the existing site, a site downtown next to the university of Louisville, and then on three greenfield sites – sites that have not been developed in the past. We’re finishing up the environmental compliance review work now.” The final site decision for the Louisville Medical Center is expected sometime in the fall of 2011.

New medical centers are, of course, the VA’s most conspicuous and often-discussed projects, but they don’t represent the totality of the department’s ambitious construction program. Three new projects are under way to provide facilities for the VA’s Polytrauma System of Care, established to accommodate the injuries suffered by many service members in Iraq and Afghanistan. “We’ve had people coming back from the field who, in past wars, wouldn’t have made it home,” said Neary. “They’ve suffered blasts, burns, loss of limbs. These are very sophisticated medical care centers. We’re building new ones to replace the existing ones in Tampa [Fla.] and in Palo Alto [Calif.], and we’re also building a new Level One center in San Antonio, Texas.”

The San Antonio Polytrauma Center, the nation’s fifth Level One center, is a cutting-edge facility, a three-story, 84,000-square-foot space integrated in the Audie L. Murphy Memorial Veterans Hospital. The center includes a ward, physical medicine and rehabilitation services, prosthetics services, and polytrauma research and support programs.

The department has also recently completed, or is currently building, spinal cord injury centers in New York; Milwaukee; Syracuse; Dallas; Minneapolis; Chicago; and Brockton, Mass. Across the country, many outpatient clinics are under way (the Fort Worth Clinic, opened in November 2010, is the largest outpatient clinic in the nation); as well as various improvements, expansions, renovations, and retrofits. The VA strives for maximum efficiency in every facet of a project, from contracting methods to the choice of building materials to power supply.

Many VA projects, some funded by the American Recovery and Reinvestment Act (ARRA), have replaced or supplemented aging power plants with renewable energy resources; VA has contracted no fewer than 40 photovoltaic projects at medical centers and national cemeteries across the nation. “For every project,” said Neary, “we’re looking for ways to include renewable energy. We’re putting in photovoltaic solar systems, and new and much more efficient heating and power plants. We’re also installing windmills at several facilities around the country to generate electricity.”

Newer VA projects also feature retrofits that ensure earthquake resistance, which has been a top priority for the department since the 1971 San Fernando earthquake, in which 49 people were killed in a partial collapse at the local VA hospital. Of the four new major projects proposed in the department’s FY 2012 budget, three have been prioritized primarily because of the seismic safety risk faced by existing facilities.

The Standard in Patient-centered Care

Anyone can build a new hospital, of course; it’s the VA’s focus on patients that places its medical centers at the leading edge of care in the United States. The VA’s new hospitals aren’t just bigger and newer – they’re better, in many ways.

“By far the most important difference [between old VA hospitals and new],” Neary said, “is the concept of patient-centered care: designing facilities primarily with the patient in mind, and having more home-like environments. In recent years we’ve had a very robust program of physical plant upgrades, with a focus on improving patient areas, improving clinic space, and getting better efficiencies. It used to be one exam room per doctor – when you finished examining a patient, you went for coffee while they cleaned the room and got the new patient in. Now we’re putting two and three exam rooms into a space, so physicians can move from room to room, and the staff has the patient in place.”

In mental health settings, the long-corridor hospital, designed like any other medical ward, with patients in individual rooms, will soon be a thing of the past in VA facilities: “We’re now building facilities that have more of an apartment-like feel to them,” Neary said. “You have something like a living room, and a kitchen area, and you might have four bedrooms or six bedrooms off that living room. So each patient has his or her own bedroom, and more of a common area with a television and other features. That’s a big deal, a big change in the model of mental health care.”

In ambulatory settings, the VA is designing spaces in accordance with its new model of patient-centered care, the Patient-Aligned Care Team, or PACT. “On a PACT team you have a physician, a nurse,” said Neary, “and you might have a clinical medical physician. You might have a mental health physician. Those folks, instead of having their offices located around the building, will be located in the clinic itself, so that they can do a better job of engaging with the patient. We’re also putting family spaces in; in the hospital rooms themselves, there are larger spaces, so a family member can not only be there for old-fashioned visiting hours, but there might be a fold-out sofa they could sleep on during the night, if it’s appropriate and could be a benefit to the patient. In our physical spaces we’re looking at ways to enhance engagement with the patient.”

The VA finds out what veterans need from its facilities in two simple ways: First, it asks. For all large projects, such as the new medical centers, development is driven in part by a council of veterans who meet regularly with planning and design teams. For facilities that have a narrower focus, a more specialized group may advise; the Paralyzed Veterans of America (PVA), Neary said, have offered their collective insight to help the VA design its spinal cord injury facilities. “PVA has their own group of professional architects,” Neary said, “who work on things like accessibility. They’re very, very knowledgeable people, and they make a big contribution to our work.”

The VA and its design partners also – like so many leading designers of patient-centered health care facilities – rely on studies of how and where patients and providers move and spend their time. Many studies involve the placement of radio frequency identification (RFID) tags on staff members, which then track their movements for up to 60 days or so, to document traffic flows and areas of congregation.

Knowing where people spend their time, Neary said, may sound like a simple thing, but such studies are actually a fairly recent development. Too often in the past, without this knowledge, facility design has allowed other factors – aesthetics, compactness, or simply the inertia of age-old practice – to nudge aside the needs of the VA’s patients. That’s not likely to happen in today’s VA medical centers and clinics. “In our new order of things,” Neary said, “we don’t want to just build a brand-new old place.”

This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.