The University of Vermont Medical Center,by Ed Barna As Fletcher Allen Health Care in Burlington prepares to open the signature architectural piece of its new Renaissance Project by the end of this month, one thing remains clear: Despite all of the controversy and financial malfeasance, a profound upgrade for the state’s largest hospital was necessary.Former Fletcher Allen CEO William Boettcher, hired in April of 1998, declared only three months later that the medical complex was “in a period of renewal.” Described by some as “no-nonsense” in his management style, and by others as a “mean” person who ruled by intimidation, he was so determined to bring the facility to a higher and possibly world-class level that he precipitated one of the state’s largest financial scandals which is still under federal investigation, and whose aftershocks continue in such things as the need to negotiate with now-unionized nurses, troubles in finding charitable donations, and the current request for a double-digit budget increase next year.But throughout the regulatory furor over price underestimates, cost overruns and hidden bookkeeping, and the legal proceedings that resulted in a two-year prison sentence for Boettcher and guilty pleas for two other high-level executives, there has been a strong undercurrent of insistence that there was a real need for a major renovation-addition project. Medical practitioners have pointed to unacceptable conditions and departmental overloads, patients have shared horror stories with the media, and Edwin Colodny, the former UVM president brought in as interim CEO to clean up after the project’s botched beginning, has been vocal about the underlying, fundamental rationale for it.”As was widely acknowledged when our original CON was approved, the need for the project is real and valid,” Colodny said in February of 2003. “The health care goals of the project are sound.” Vermont College of Medicine Dean Dr Joseph Warshaw weighed in as a supporter, arguing that it was already difficult to attract doctors to the state’s only teaching hospital, and that solving that problem would not be possible as long as he kept getting letters and emails from practitioners about problems like a serious shortage of operating rooms. Colodny went as far as saying the lack of state-of-the-art medical care could be factor in IBM deciding to leave Chittenden County.’The impact of being less than the best we can be in the state of Vermont would be an economic disaster for the state,’ he said.It is now almost four and a half years since the Renaissance Project broke ground, and the institution that formed in 1995 from the amalgamation of Fanny Allen Hospital, the Medical Center Hospital of Vermont, the University Health Center and the University of Vermont has been transformed. A more efficient and effective power plant and an expanded birthing center with more options for families were completed last May, new pre-operative and post-operative facilities were ready in February, the upgraded laboratory came on line in March, and the new emergency department was ready in July.Much of the heavy lifting to prove the worth of the project will fall onto the shoulders of CEO Melinda Estes. Estes is a medical doctor with a proven record of hospital administration. Like Colodny, she’s direct and confident, but she’s also a doctor and the MD after her name gives her immediate “street-cred” in an industry with a culture of egos.When the Ambulatory Care Center opens this month, it will reflect a major shift in medical care toward outpatient services, but perhaps most noticeably to the public, a 1,200-space underground garage with quick elevator connections to medical specialty clinics, will help alleviate a chronic parking shortage. Not a complete list, but it’s indicative of the degree of change.After an open house for employees on September 10, a formal dedication on September 15 (congressional delegation, governor, mayor all expected), and a public open house on September 17, the new “front door” is scheduled (as of mid-August) to open on September 26. The glassed facade of the three-story Ambulatory Care Center, looking toward the College of Medicine and College of Nursing and Health Sciences to the west, may recall how the project ballooned in cost from a proposed $173.4 million to an estimated $367.3 million; to others it may symbolize a new and forward-looking era.To put it another way, a tipping point may be at hand. Though no one is suggesting that the end justifies the means the judicial system has said the way the project was put across amounted to a criminal conspiracy, and it has been punished as such henceforth the strengths of the new facility will have a chance to prove their worth. These may quickly come to predominate in the minds of those who encounter the medical center without memories of its past.Most obviously, keeping the facility current may help attract or keep patients who might otherwise seek care in Lebanon, NH, or in Albany, NY. (This in turn has created pressure on other Vermont hospitals, adding to the rationale for construction projects in Rutland, Middlebury, and Berlin.) In ways ranging from shorter wait times to improved cross-specialty consultation to greater patient privacy to better access to educational medical information for family members, care is expected to improve.The facility’s economic health matters because it is the state’s second-largest employer (about 6,000 employees, roughly 4,600 full time equivalents), provides work for about 1,100 Vermont-based contractor and vendors, purchases about $90 million worth of Vermont goods and services each year, and puts nearly $11 million in the state’s coffers through employee withholding taxes alone. Economic and Policy Resources, Inc of Williston said in 2003 that each job at Fletcher Allen, combined with the capital investment there, produced another job elsewhere in the state, and the combined personal income of these direct and indirect jobs amounted to $847.4 million.Beyond that, the Renaissance Project may have broad implications for economic development, in ways that are not so easily measured as admission rates and lengths of stay. The medical schools bring a surprising amount of research money into the state: over $86 million in 2004, counting both Fletcher Allen clinical research and College of Medicine grants. The findings of that research in some cases could become in some cases have become the basis for commercial activity.Executive decisions on whether a company should expand, relocate, or stay in Vermont may hinge on the state’s quality of life, given that transportation and energy costs are unlikely to seem advantageous, and that can include the quality of medical care. To the extent that a top-notch medical center appeals to first-rate medical students, that the state as a whole may benefit because with predictable regularity some of them decide one of their long-term goals will be to return. At that point in their careers, like salmon that go to the sea to mature then return, they may bring new strengths to their communities, as well as financial assets.For better or worse, the Renaissance Project has aligned itself near the most generous end of the spectrum of possible valuations of quality medical care. The question “How much is a human life worth?” gets answered much less often than the question “How much do we have to spend?” which implies an answer to the first question but avoids making any case-by-case calculations.At Fletcher Allen, the money has been spent, and the post-construction phase, beside figuring out how to make the payments, will include a chance to connect the spending with the medical mission. From a purely Hippocratic standpoint, not tallying the project’s benefits might be regarded as tantamount to not believing a human life has any worth, and neglecting that side of what has happened might itself be considered a form of accounting mismanagement.The DifferenceIn looking at how the Renaissance Project has changed Fletcher Allen, a good place to start would be the specialty many patients encounter first: the emergency services department that opened July 13. Its previous incarnation had clearly become outdated, serving about 52,000 patients a year with facilities originally intended for only about 30,000. Not only does the hospital have the only emergency department in Chittenden and Grand Isle Counties, it is the only one in northern Vermont with the equipment and staff to qualify as a Level One Trauma Center. All this was being funneled into two ambulance bays.There are now five bays, the department is twice as large, and instead of 23 beds there are 45, plus 10 dedicated to trauma and major resuscitation efforts. An elevator from the area can whisk serious cases up to an operating room. Coordination is better with the many medical specialties that get called in as necessary: surgery, oral surgery, cardiology, orthopedics, neurology, radiology, pediatrics, oncology, obstetrics and gynecology, psychiatry. Several of these departments have dedicated emergency area suites set up to facilitate their work.For the sake of faster and more accurate diagnosis, the emergency department has its own radiology area, with two X-ray machines and a Philips 64-slice computed tomography (CT) scanner. The latter is the only one of its kind in New England, and one of only a few in the entire country.Dr Ruth Uphold, director of the department, said the staff had played an active role in designing the new facility. She and the assistant director “were included from the very beginning. We consulted or checked on every issue.”The biggest difference, she said, is that they can now deal with problems in a timely fashion. Before, “we were swamped,” she said.Thinking of what it would be likely if there were a major disaster or a terrorist incident, the staff “absolutely” feels better about how they would respond, Uphold said. “We have actually done a drill called Red Clover,'” she said, to help develop the teams and lines of communication necessary for such an event. She said they and emergency services officials like fire chiefs all see the greatly improved decontamination area as a plus for dealing with hazardous materials or biological threats.There is always a transition period, during which everyone is getting used to old equipment being in new places and so on, Uphold said. “With any change, the first few weeks can be stressful.” But now, “it’s becoming second nature.”Among the positive changes that the staff is learning about, the department now utilizes the Patient Archive Communication System, Uphold said. Medical records can be accessed by computer, family physicians can be brought into the picture, tests don’t have to be unnecessarily duplicated, and comparing old to new tests (X-rays, for instance) can spotlight problems that have developed.”That ability is a nice advance,” Uphold said. And when emergency patients need additional tests, it is far more convenient to arrange them a kind of coordination that will become even better when the physician offices now at the former Medical Center Hospital of Vermont building move to their spaces in the new building.Less dramatically, but of importance to families, the new unit offers more privacy in treatment areas and a larger waiting area with a play space for children. Some emergencies involve law enforcement issues; in such cases, families may be glad to learn that all internal entrances need a pass card and the one external entrance is monitored around the clock by a security officer. When admission to the hospital is necessary, bedside registration facilitates it.What’s true of the emergency services department is true in similar ways for other medical specialties: planning with practitioners involved, space designed around the patient and family experience as well as being physically expanded, better integration of everyone’s expertise and equipment. Looking ahead, the design includes a great deal of flexibility in how rooms are used in some cases different medical specialties will rotate in and out of the same area during the week in recognition of the way medical advances can change hospital practices.If there is one area of the revamped facility that could symbolize the revolution that the Renaissance Project embodies, it’s the one that people will use as the “front door” to the medical center campus: the Ambulatory Care Center. Outpatient care, including surgery that in earlier decades would have required hospital admission, is more and more becoming the norm.”Fletcher Allen is currently providing its outpatient care in a facility designed as an inpatient hospital in 1924,” said one of the medical center’s statements. In 2004, there were 23,288 admissions to the 562 licensed beds; over the same time period, there were 459,586 outpatient visits, as well as 747,848 professional visits (not including radiology and lab work). The 6,737 inpatient surgeries were matched by 13,238 outpatient surgical procedures.Cynics have characterized the trend toward shorter patient stays and reliance on in-and-out one day procedures as discharging people “sicker and quicker.” Others who are aware of the growing danger of hospital infections from antibiotic-resistant drugs take a different view. In any case, at a time when medical dollars are running short, efficiency matters.”The new Ambulatory Care Center will support efficient outpatient care delivery systems that will be more convenient for both patients and health care professionals,” says the medical center’s own summary. “Although Fletcher Allen is already one of the lowest in cost of all 126 academic medical centers nationwide, the new outpatient facility will result in substantial operational savings over time.”Getting The Third DegreeAny judgment about the costs and benefits of the Renaissance Project needs to take into account its likely effects on the medical center’s role as a branch of academia. Fletcher Allen’s own summary goes as follows:”This project takes advantage of a once-in-a-lifetime opportunity to create Vermont’s first truly integrated patient care and academic health sciences campus. As Fletcher Allen breaks ground on the Ambulatory Care Center (patient care) and collaborates with the University of Vermont to build the new Education and Conference Center (education), the construction of UVM’s new Health Science Research Facility (research) is already well under way. Together, these three projects represent a significant investment in the two organization’s joint tripartite mission of patient care, education and research.”Some of the pathological research takes place at the University of Vermont’s laboratories, but some also occurs at the FAHC department of pathology and laboratory medicine. In other words, two kinds of lab work are going on, which sometimes overlap. From the patient’s point of view, it will make a difference that the new lab on the first two floors of the Ambulatory Care Center will consolidate services that had been in five locations on two campuses. The new lab’s design is meant to facilitate staff flexibility, encourage cross-training (assisting the education of interns and residents), and ease the flow of specimens through the area. To help with the latter goal, there is a central receiving area that uses new automated technology to prepare and sort specimens for faster routing to their appropriate destinations.This is a big part of what goes on at the hospital. More than 300 people are employed in the lab department, including 30 board-certified pathologists. One division supervises more than 30 off-site testing locations, not counting the hospitals around the state for whom Fletcher Allen serves as a reference laboratory. Telemedicine has also expanded the reach of this, and several other, departments of the medical center.As for research, few realize that the General Clinical Research Center at Fletcher Allen/UVM is one of only 78 such facilities in the country, and the only one in northern New England. Ongoing projects are working on possible treatments for heart disease, cancer, Parkinson’s disease, diabetes, and more.The Vermont Cancer Center at UVM/Fletcher Allen is one of only 39 National Cancer Institute-designated comprehensive cancer centers in the country. “Comprehensive” here reflects a quadruple role: research, prevention, patient care and community education.Increasingly, in the age of the Internet, patients have been researching their own ailments and bringing their findings to physicians. In the last two years, the College of Medicine’s Dana Library has seen the number of public inquiries pass the number made by their own faculty. Before the Renaissance Project, this trend did not have much support: there was a Health Resource Center in the lobby of the medical center’s McClure Building, but it was so small it could serve only two or three people at one time. The new Education and Conference Center, considered an integral part of the Ambulatory Care Center, is seen as a way of joining patient care with the College of Medicine’s research and educational missions.You Can Go Home NowA few pieces of the Renaissance Project have yet to receive their finishing touches, such as the underground parking facility. Beaumont Drive is to be relocated, so that it no longer divides the College of Medicine from Fletcher Allen. Inpatient psychiatry is will be expanded in the Shepardson Building.But the end is almost in sight for a project that could be said to date back to 1989, when the first study was done to identify alternatives for creating a new Ambulatory Care Center. All over, that is, except for the fundraising, which so far has brought in $18.5 million (contact the Office of Development at 847-2887 or email [email protected] (link sends e-mail)(link sends e-mail)). The institution that in 2004 allocated $16.8 million to charity care, and provided another $3,603,009 through its Community Benefit Programs & Support, needs some help itself, along with more than a little healing.Ed Barna is a freelance writer from Middlebury.