Medical Office Build-Out: What to Plan For

A build-out plan starts with how care will be delivered, not with a floor plan. Write down the room types you need, how many of each, what happens in each, what equipment goes in them and how patients and staff move between them. That program is the document an architect prices and tests against a suite. It also forces partners to agree on what they are building before anyone draws a wall.

Then test real suites against it. A suite that looks fine on a tour can fail on column spacing, where the plumbing risers are, or what power the building can bring to the floor. TAG can run the search and the lease negotiation in step with your design team, so that technical findings become lease terms before you commit.

Each of these should be reviewed by your engineers. Requirements depend on what you do, where you are and the codes your jurisdiction has adopted.

• Plumbing. Attorneys at Winstead note that many medical tenants have sinks in each exam room. Ask where the risers and drains are relative to your rooms, whether the slab must be cut, and how far the run is. Stacking plumbing walls between rooms is a common way to shorten it, and your engineer can tell you whether it works here.
• Power. The same attorneys point out that x-ray, MRI and other equipment use more electricity than standard office equipment. Get each machine's specifications to your engineer, and check capacity against any lease limit on electrical consumption.
• HVAC. Ask about zoning, hours, after-hours charges, and whether equipment rooms or procedure rooms need separate cooling, ventilation or exhaust. Building systems that shut off in the evening can be a problem for refrigeration and for rooms with heat-producing equipment.
• Compressors and vacuum. An attorney quoted by The Habitat Group notes that medical and dental offices doing procedures often need a compressor for drilling and suction, and that tenants may prefer to place them away from treatment areas for noise and space reasons, which can mean negotiating access if the location is common area.
• Sterilization and clean areas. Plan where instruments are processed, how clean and dirty flows are kept apart, and where waste is stored before pickup. Infection-control and state rules vary, so check them for your specialty.
• Privacy and accessibility. Accessible exam rooms and routes, reception layout and sound between rooms all shape the plan early. They have their own guides in this resource center.

Not every practice needs piped gas, and the answer changes the project. King County, Washington's public health department describes how NFPA 99, the Health Care Facilities Code, sorts systems into four risk categories according to the likely consequences of failure. Its examples show how the use drives the category: an ambulatory surgical center or a reconstructive surgeon's office with general anesthesia and piped patient gases is listed as Category 1, a procedural sedation site with piped patient gases as Category 2, and a typical doctor's office with no piped patient medical gases as Category 4. It says a risk assessment should be conducted.

That page is one county's explanation, and the edition and rules in force where you are may differ. Ask your engineer which requirements your local authority applies. Find out early whether your plan calls for piped gases, because that decision affects installers, testing and schedule, and it may affect what a landlord permits in the building.

State rules are a large part of imaging. FDA says individual states have regulations and guidelines that apply to imaging facilities and personnel. Rules differ, so these two examples show the type of thing to check, not a national standard:

• Illinois. The rule at 32 Ill. Adm. Code 360.30 covers the use of x-rays in the healing arts, including registering x-ray equipment with the state agency, and says each installation shall have the barriers necessary to comply with the cited state radiation rules.
• Michigan. The state says radiation shielding review and approval should be obtained for many types of x-ray installations, and that re-approval should normally be obtained when equipment is replaced or major room renovations are made. It says a plan review can generally be completed within 2 to 6 weeks. Timelines can change, so ask.

Ask your equipment vendor and, where appropriate, a qualified medical physicist what your state requires and when. Shielding design depends on factors such as workload, equipment, and who occupies adjoining spaces, including space next door, above and below you. Lease-wise, the New York Real Estate Journal's guide to medical leases suggests addressing certified plans, insurance and whether you must remove lead shielding at the end of the term.

Some jurisdictions apply healthcare design standards in addition to the general building code. The Facility Guidelines Institute (FGI) tracks the use of its guidelines, including outpatient guidelines, and says state use differs. FGI tells readers to confirm regulations with the state department of health or other responsible state agency, and not to rely on its map for final project decisions.

Whether your project needs a health department review, a license or a special inspection depends on your state and on what you do, such as procedures, anesthesia or imaging. Ask your architect to make a list of every approval and agency for your specific practice and to put the timing on the schedule. New and altered space also has to meet the ADA Standards, according to the Department of Justice, and medical waste is regulated mainly at the state level, according to EPA.

1. Write the clinical program and equipment list with your clinicians and administrator.
2. Hire an architect, then mechanical, electrical and plumbing engineers with clinical experience, before you choose a suite.
3. Test fit your short list. Have engineers walk each suite and check risers, power, HVAC, floor loading and adjoining occupants.
4. Get rough pricing, and use it in the letter of intent to negotiate the allowance and landlord work.
5. Have your attorney review the lease alongside the work letter, including approval rights, restoration and rent start date.
6. Get a list of required permits and approvals, and start with the long ones, such as shielding reviews and any health department submittal.
7. Order long-lead equipment and coordinate delivery and installation with construction. Vendors often need rooms in a specific condition first.
8. Plan final inspections, physics or gas testing where applicable, and any payer or licensing steps before patients arrive.
9. Leave time before your old lease ends. A holdover in your current space is an expensive way to find out the schedule slipped.

Tie the rent start date to something you control, or at least understand. If rent begins on a fixed date and approvals run late, you pay for space you cannot use.