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Organizations are building fewer new or replacement hospitals, unwilling to proceed with projects in a slow economy and facing a year of uncertainty as they await decisions that will affect key aspects of reforms and even their constitutionality.

Accompanying the financial restraint is a shift in strategy prompted largely by the Affordable Care Act, for the surge in patients it is expected to bring after coverage expands in 2014 and its increased emphasis on patient safety and quality of care.

Hospitals and systems appear to be scaling back on the patient-pleasing but costly "hospital-as-hotel" approach and focusing more on maximizing value and improving medical outcomes. Organizations anticipate spending more on renovations than new construction in 2012 for a second straight year, the survey indicates. They also plan to build far more ambulatory or outpatient facilities than acute care hospitals in the next three years. Data centers and medical office buildings also are a growing priority.

Capital budgets aren't taking a hit as they did after the financial crisis of 2008–09, but funds still are limited and cash-conscious organizations are behaving differently. Survey respondents say they are less inclined to borrow money to pay for new facilities. They are giving projects more scrutiny based on return on investment. And those that have difficulty accessing credit are partnering with other hospitals.

Evidence of caution on new hospital construction because of reform is clear from survey results: Only 19 percent of the 531 ASHE members who responded say new construction will proceed without changes. Another 13 percent say they will go ahead with modifications, and the rest either say plans are being reevaluated (26 percent), are less likely to proceed (19 percent) or definitely will not proceed (23 percent). Nearly three-fourths also say they will revise, review or possibly not go ahead with planned renovation projects, although fewer than 10 percent say they will suspend them.

The survey also shows that the shift in priorities from traditional hospitals to smaller, neighborhood or satellite facilities is accelerating. Future projects most frequently cited by survey participants in response to reforms are emergency departments, 17 percent; outpatient facilities in neighborhood settings, 16 percent; medical office building expansions, 16 percent; and primary care clinics and urgent care centers in neighborhoods, both 14 percent.

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