For the first time since the Affordable Care Act took effect, most hospitals and systems are addressing bricks-and-mortar questions in addition to the long list of quality, clinical and economic issues associated with the legislation. That's a key finding from the 2014 Hospital Construction Survey conducted by Health Facilities Management, Trustee's sister publication, and the American Society for Healthcare Engineering of the American Hospital Association.

More than half of respondents — 51 percent — said they are considering the ACA in senior leadership discussions about potential changes needed to existing facilities or campus design. That's up from 34 percent of respondents the prior year who said that the legislation was playing a role in senior-level construction planning discussions.

It's a significant change from years past when health care construction focused on building inpatient beds and increasing other acute care facilities to enhance curb appeal and gain market share.

The online survey, completed by nearly 500 hospital and health system executives nationwide in late 2013, shows a bigger focus on ambulatory care settings, urgent care and emergency department patient flow. One-fifth of respondents said they have an ambulatory care construction project under way or planned in the next three years. And one-third said they are or will in the next three years construct new, replacement or renovations of EDs.

In terms of what future facility development plans are being considered in response to the ACA, 22 percent said medical office building expansion, up from 16 percent in 2012; and 18 percent said new medical office building construction, up from 15 percent in 2012. Some 22 percent said outpatient facilities in neighborhood settings, up from 15 percent the prior year; and 21 percent said primary care clinics in neighborhoods, up from 16 percent in 2012. And 17 percent of respondents said ambulatory surgery centers are being considered, up from 11 percent in 2012 and 2011.

Comments from survey participants illustrate these trends:

• A Midwestern hospital system is "purchasing physician practices and moving them around the community … and we are considering building medical office buildings at two facilities to house surgical and physician practices to get them near hospitals."

• A large Texas health system is "building more outpatient clinics to reduce emergency care wait times and ease overcrowding."

• A hospital in the Southeast is "modifying existing space to improve emergency department patient flow and volume."

• A Great Plains hospital is "looking at new service delivery models changing to a greater percentage of business based on outpatient care."

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