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Staff Report 427-07
City of Palo Manager’s Report FROM:CITY MANAGER DEPARTMENT: PLANNING AND COMMUNITY ENVIRONMENT DATE:NOVEMBER 26, 2007 CMR: 427:07 SUBJECT:IDENTIFICATION OF ISSUES FOR THE EIR AND DEVELOPMENT AGREEMENT NEGOTIATIONS REGARDING THE STANFORD UNIVERSITY MEDICAL CENTER; PROJECT UPDATE AND REVIEW OF COMMUNITY INPUT RELATED TO LAND USE, HOUSING, TRANSPORTATION, SUSTAINABILITY AND OPEN SPACE ISSUES; CITY COUNCIL INITIATION OF CHANGES TO TITLE 18 (ZONING) FOR HOSPITAL AND RELATED USES, SO THAT PROPOSED ZONING CHANGES CAN BE STUDIED AS PART OF EIR; AND STATUS OF ENVIRONMENTAL AND ENTITLEMENT REVIEWS. RECOMMENDATION Staff recommends that the City Council 1) review and provide input regarding key issues related to the Stanford University Medical Center (SUMC) Facilities Replacement and Renewal Project to inform the EIR process and form the basis of negotiations for the development agreement, 2) initiate changes to Title 18 (Zoning) to accommodate hospital and related uses (including housing and open space) so that the proposed changes can be studied as part of the Ell{. BACKGROUND Review for this project has been divided into two phases: Phase I (Information Sharing and Preliminary Area Plan) from December 2006 through July 2007, and Phase II (EIR and Entitlements), from July 2007 through the end of 2008. The Phase I activities helped to focus discussion on key issues of concern to be reviewed during the Phase II (EIR and Entitlement) process. The start of Phase II began with the submittal of development applications on August 13, 2007, for the SUMC and on August 21, 2007, for the Stanford Shopping Center. Phase II (EIR and Entitlements) of the review process will culminate with the City Council’s review of the EIR, development agreements, and other entitlement applications. Staff has provided the Commission and Council project review updates and requests for comment throughout this process. On December 13, 2006, staff recommended to the Commission to begin study sessions for this project. On December 18, 2006, the City Council authorized staff to commence the process of review, and authorized the City Manager and City Attorney to negotiate a Development Agreement. The Commission held study sessions on January 24 and April 25, 2007. Information provided to the Commission included an overview of the Area Plan and proposed key Area Plan objectives. On May 14, the City Council held a study session to review the conceptual project plans and the key Area Plan objectives. The Commission continued to review the Area Plan at its meetings of June 27 and July 11, 2007, and recommended changes to the Area Plan on July 23. The Area Plan is being revised by the City based upon Commission and Council direction. City of Palo Alto Page 1 On September 5, the Commission offered comments on the scope of issues and alternatives for the EIR. On September 24, 2007, the City Council held a public scoping meeting for the EIR. City staff and the Commission have sponsored five community meetings on February 27, June 11, October 4, October 18, and November 1, 2007. Stanford representatives have also hosted community meetings targeted around key hospital issues. On November 14, 2007, the Commission provided recommendations to the Council on the attached Issues List for the SUMC and SSC (Attachment A). DISCUSSION The purpose of this meeting is to allow for Council review and comments on the identification of issues to be used for potential mitigation of environmental impacts and as the foundation for negotiations of the Development Agreement, and to initiate zoning amendments that will be further analyzed in the EIR, and may be part of the Development Agreement. A Development Agreement is a negotiated contract between the city and a project applicant, and allows broad discretion for the public agency and private applicant to work out project requirements and to require compensating community benefits above mitigation of project impacts. A Development Agreement provides assurance to the applicant that the approved project may proceed subject to the policies, rules, regulations and conditions of approval applicable to the project at the time of approval. The agreement applies regardless of any changes to city policies, rules and regulations after such approval. In the absence of a Development Agreement, the City would retain substantial discretion to change the land use and zoning designations, policies, rules and regulations applicable to the project after project approval. In exchange for the vested development rights granted under the Development Agreement, the applicant agrees to provide infrastructure, pay fees and/or provide other benefits to the City that may not normally be required of the applicant under state and local planning, zoning and environmental laws. Issues List A Draft Issues List for both the SUMC and Stanford Shopping Center (SSC) projects was compiled by City staff based on aggregated comments from Council and Commission study sessions and hearings, community forums, other City staff, and the applicants (Attachment A). It represents a record of a broad spectrum of thoughts about what should be considered in the review and evaluation of these projects and during the Development Agreement negotiations and E]R preparation. It can be used as a tool to help organize the discussion of topics for negotiation of the Development Agreements, but does not represent a final and comprehensive list of issues. The Draft Issues List contains key issues, community benefits and mitigations organized around six key topic areas: Land Use and Open Space; Housing; Transportation and Linkages; Sustainability; Utilities and City Services; and Fiscal issues. Each section includes reference to the corresponding Area Plan objective and includes a notation as to which project (or both) the issue applies. The specific impacts have not yet been identified for mitigation; however, the mitigations in the list are a starting point for future discussions regarding the expected categories of impacts for projects of this size and magnitude. It should be noted that the City and the applicants are required under the California Environmental Quality Act (CEQA) to mitigate the City of Palo Alto Page 2 potentially significant impacts of the projects to the extent feasible. Consequently, certain mitigation measures will be incorporated into the projects or imposed as conditions of project approval in order to comply with CEQA. By contrast, the community benefits and mitigations negotiated by the City as consideration for the Development Agreement are not limited to the mitigations required under CEQA. Mitigation required under CEQA should not be confused with the community benefits and mitigations negotiated by the City in exchange for the Development Agreement. Planning and Transportation Commission Review The Commission reviewed the draft Issues List at its meeting on November 14, 2007 and has provided recommendations to the Council for modifications to the list (Attachment B). The Commission’s draft minutes of the November 14 meeting are attached as Attachment C. Housing Sites Identification of housing opportunities in and around the project areas will be an important component of the Development Agreement discussions with the applicants. The Draft Area Plan that has been developed for the SUMC project includes the following key plan objective with regard to housing: "The Area Plan shall identify strategies for accomplishing housing with a focus on below-market residential units which wouM be available to help accommodate employment generated by the project. " The Draft Area Plan describes four potential housing sites in the vicinity of the project area. Two of the sites are within the City of Palo Alto: an existing housing site at the comer of Pasteur Drive and Welch Road that could accommodate approximately 100 housing units and the Red Cross site, adjacent to the Palo Alto Transit Center that could accommodate approximately 30 housing units. In addition, two housing sites are located near the project sites in unincorporated Santa Clara County. Stanford’s General Use Permit (GUP) allows development of 200 additional housing units for hospital residents and post-doctorate students at the Quarry/Arboretum site (GUP Site H), and 150 additional housing units for hospital residents and post-doctorate students at the Quarry/El Camino site (GUP Site I). Other housing sites have been identified as part of the overall housing requirements defined the GUP. Table 1 describes the GI~ housing areas and the approximate number of units that could be built in each area. Table 2 describes the housing units that would be required at each level of campus development, as well as the net housing units available beyond what would be required by the GUP. Attachment D contains a map of the potential housing sites identified in the Draft SUMC Area Plan (Sites 1,2,3 and 4) and significant housing sites in the GUP (C,F,G,O and Area B). This map illustrates the relationships between the identified housing sites in and around the project area and the Stanford University campus. City of Palo Alto Page 3 Table 1: Proposed Housing Development Potential and GUP Sites Table 2: Housing Requirement Linkage to Academic Development A B C D E F G H I J K L M N O Total 100 125 1,145 25O 9-75 102-195 367 2O0 150 2-18 1-12 1-9 200-372 2,625 to 3,018 units 500,000 605 1,000,000 1,210 1,500,000 1,815 1,500,000 to a 1 unit per 884 maximum of square feet of 2,035,000 development = 605 units 2,420 units 3,018 units 598 units Total Total GUP Housing units, max Net Housing units potentially available beyond development linkage Initiation of Proposed Zoning Ordinance Amendments The proposed project would necessitate rezoning of much of the SUMC area to a new Hospital District (or some other mechanism) to accommodate the increased floor area and height proposed by Stanford. The rezoning would constitute a portion of the project description for the EIR and the entitlements required. Zoning Ordinance Section 18.98 provides that the City Council may initiate a zoning text amendment. Initiation of the zoning ordinance amendment(s) would allow staff to review and analyze the proposed text changes as part of the EKR, and to begin the public review process. It does not in any way imply support for or approval of the revisions as proposed, but begins the review process for evaluation of-the appropriate zoning for the project. Stanford’s application states that given the unique nature of the SUMC, and the needs particular to provision of healthcare in a hospital environment, it is proposed that the City initiate approval of a new zoning district that would include development standards designed to accommodate the proposed project, as well as to provide for regulatory framework for ongoing project design and enable a relatively minor amount of potential future expansion. Attachments E and F include the applicant’s proposed expanded text from the SUMC Application. Again, initiation of a zoning text amendment does not bind the City to evaluating only what the applicant proposes, but will allow staff and the Planning and Transportation Commission to recommend zoning that would be compatible with a final recommendation on the project. As part of this process, staff will also analyze whether related zone change amendments will be needed to address related hospital development and other anticipated project impacts. The Comprehensive Plan amendments do not require Council initiation since the Municipal Code allows such amendments to be initiated by the property owner. City of Palo Alto Page 4 Proiects Update In addition, this report provides the Council with an update on the following activities: 1) 2) 3) 4) 5) 6) Community Issue Meetings Community Practitioners Peer Review of the SUMC Hospital Programs Urban Design Consultant Environmental Impact Report (EIR) Project Timeline Community Meetings Summary Following the recommendation of the Commission, City staff and the Commission sponsored three issue-oriented community meetings to allow community members an opportunity for a more in depth discussion of the key topics raised during Commission and Council meetings. The meetings focused on the following topics: ¯Land Use and Housing - October 4, 2007 ¯Sustainability and Open Space - October 18, 2007 ¯Transportation and Linkages - November 1, 2007 All the meetings were held in the Palo Alto High School library. Approximately 10-15 members of the public attended each of the meetings. Prior to the start of each meeting, City staff and project representatives were available to informally discuss the projects and answer questions. Each meeting included an introduction by City staff with an overview of the topics to be discussed. The discussions were structured with an open format to allow attendees to fi’eely discuss the given topic. Attachment G includes a summary of public input received at each meeting. Community Practitioners During Commission, Council and community meetings a concern was raised about the status of the existing community practitioners who have their practices in and around the Project area. Stanford has prepared a memorandum to describe their efforts to address the need to provide space for community practitioners (Attachment H). Much of the building area at the Hoover Pavilion site presently serves SUMC clinical and clinical research purposes. As the outpatient campus in Redwood City develops, the current uses of Hoover Pavilion are expected to migrate towards private medical practices and to house non- Stanford medical offices displaced by the demolition of 701, 703, and 1101 Welch Road buildings. The SUMC application proposes new buildings be added adjacent to the Hoover Pavilion to support medical office and clinical practice requirements, including those for non- Stanford community health providers. This total future need is anticipated to be approximately 200,000 square feet with approximately one-half identified for Stanford Hospital and Clinic medical office and clinical use. In addition, the SUMC has master-leased medical office space in Menlo Park, of which approximately 40,000 square feet could be available to non-Stanford health providers. City of Palo Alto Page 5 Hospital Peer Review The City has retained Marlene J. Berkoff, FAIA, an architect and economist familiar with hospital planning and design, to provide the City Staff and City decision-makers with a peer review of the proposed medical facilities. Her peer review investigations are aimed at determining to what extent Stanford’s proposals fall within the norms of current-day hospital planning and construction, identifying areas where Stanford may be outside the norms, and analyzing the underlying rationale and impact of the proposed projects’ scope and variances from norms, where applicable. Ms. Berkoff will present her preliminary review findings to the Council at the meeting. Attachment I contains the preliminary report and executive summary. Her analysis contains discussions of the following sections: A.Bed Numbers - the fundamental "driver" of space needs B.Private Patient Bed Rooms C.Size of Patient Bedrooms D.Operating Rooms E.Emergency Department Issues F.Imaging Department Growth and Change G.Overall Hospital Space Growth and Hospital Size: Additional Factors to Consider H.Building Height Comparisons - Floor-to-Floor Heights I.Hospital Configuration - vertical vs. horizontal balance - relative to overall building height J. Services located off-site K. Staffing L. Summary The overall assessment is that Stanford’s plans are not in any significant way outside standard norms for good planning and current-day medical practice, especially for a premier academic teaching hospital that is being designed to serve at least 25-30 years into the future. If Stanford’s patient bed projections are reasonably accurate and acceptable, then the rest of the space needs follow in a rational fashion and do not appear to be outside normal ranges. Urban Design Consultant In addition to the hospital peer review consultant, the City is expected to retain Bruce A. Ftflcuji, AIA, Principal of Fukuji Planning & Design, to assist the City with the review of SUMC and SSC’s overall site plans for their relationships to surrounding land uses, linkages and circulation and to analyze the compatibility of the massing with surrounding buildings. The primary focus of the evaluation will be to assess the availability and sufficiency of pedestrian-friendly circulation connections between the SUMC project, Shopping Center, Palo Alto Transit Center, Downtown, Town & Country Village and adjacent residential areas. He will look for opportunities to internalize trips, encourage walking, biking or transit and to create an attractive, vibrant place. He will also evaluate the proposed height, massing and bulk of the proposed buildings and parking structures to determine if they are in scale and character with their surrounding environments. He will provide input on proposed alternatives for the EIR and will present and review the Projects with the Architectural Review Board. City of Palo Alto Page 6 EIR Status The Notice of Preparation (NOP) for the SUMC Facilities Replacement and Renewal and Stanford Shopping Center Expansion EIR was issued on August 22, 2007, and the review period on the NOP closed on October 1, 2007. During the review period, the City received oral comments from the Planning and Transportation Commission on September 5, 2007. On September 27, 2007 the City Council conducted a scoping session during which oral comments from public and the Council Members were received. The City also received comments during the June 11, 2007 community meeting. Eighteen comment letters were submitted by various agencies and individuals during the comment period. A scoping report, which summarizes all written and oral comments received during the NOP review period, is currently being prepared by staff and the consultant and should be finalized by end of November. Concurrently, the EIR data collection efforts, definition of alternatives, and project analysis are ongoing. The draft technical studies that will support the EIR, including the Traffic Study, Housing Needs Analysis, review of historic resources, visual massing simulations, and Water Supply Assessment, will tentatively be drafted by completed by late November through early December. The first Administrative Draft EI~R, and internal working document, will be submitted to the City by the EIR consultant in February 2008, and a Draft EIR is scheduled for publication in late June 2008. The Final EIR is scheduled for publication in late November 2008. Project Timeline A revised project timeline for the SUMC project is contained in Attachment J. The timeline for Phase II of the SSC is similar and is not contained in this staff report. The timeline has been adjusted to accommodate the required environmental analysis and public review period. As mentioned above, the Draft EIR is expected to be available in late June 2008 with public hearings to be held in late summer. Proiect Information on City Website Detailed project information can be found on the City’s website at v~¥w.city.palo- alto.ca.us/knowzone. Additionally, comments and .questions can be sent to the City’s Project Manager, Steven Turner, at steven.turner@cityofpaloalto.org. NEXT STEPS Work will be performed on the EIR and development agreement negotiations, with periodic reports with the Commission and Council. PREPARED BY: DEPARTMENT HEAD: STEVENrTURNER /Director of Community and Environment City of Palo Alto Page 7 CITY MANAGER APPROVAL: FRANK BENEST City Manager ATTACHMENTS B. C. D. E. F. Go H. I. J. Draft Issues List Planning and Transportation Commission Comments on the Draft Issues List November 14, 2007 Planning and Transportation Commission Minutes Housing Sites Map SUMC Application Materials regarding zoning SUMC Application Materials - Zoning Designations Existing (Figure 1-3a) and Zoning Designations Proposed (Figure 1-3b) Community Meetings Summary Memo from Stanford re: Community Practitioners Hospital Peer Review Executive Summary and Report Project Timeline COURTESY COPIES William T. Phillips, Stanford Management Company Jean McCown, Stanford University Public Relations Office Charles Carter, Stanford University Planning Office Art Spellmeyer, Simon Property Group John Benvenuto, Simon Property Group Anna Shimko, Cassidy, Shimko, Dawson, Kawakami City of Palo Alto Page 8 Attachment A STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST This Draft Issues List for both the SUMC and SSC projects was compiled and created by the City of Palo Alto staff based on aggregated comments from council and commission study sessions and hearings, community forums, from internal city staff, and the applicants as well. In that regard, it represents a record of a broad spectrum of thoughts about what should be considered in the review and evaluation of these projects, and during the Environmental Impact Report preparation, and Development Agreement, as applicable. Each item on the list will be discussed at some point during the review of the project. It may be determined through this review that an issue is not relevant and can be dropped. Also, it can be used as a tool to help organize the discussion of topics for negotiation of the Development Agreement during Phase 2, but does not represent a final and comprehensive list of issues. 1.Parks X X 2.Libraries, Community Centers X X 3.School System Capacity X X Updated November 7, 2007 1 STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST 4.Within SUMC: Pasteur Median, North Garden, Landscaped Gathering Areas Near SUMC and SSC: El Camino Park, San Francisquito Creek Streamside, Arboretum Additional Open Space protection for areas not controlled by5.hospitals 6.Transfer of development rights for foothill preservation 7.Timeline for open space preservation Accommodation of community practitioner space for doctors and dentists. (Is there adequate space? Where is it proposed? Timing?) X X X X X X 9.El Camino Design Guidelines for buildings X 10.Height (vs. open space)X X 11.Hotel location and size X 12.Historic Preservation X 13.Services adjacent/within Stanford West, Oak Creek Apartments X 14.Surge capacity during emergencies X 15.Provision of Market rate vs. Affordable Units X X 16.Unit Types X X 17.Fees vs. Sites vs. Production X X Identification of Sites18.(County & Cit~, locations; Zoning Issues)X X 19.Housing Site X X Updated November 7, 2007 2 STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST 20. 21. Expansion, Integration, Coordination between VTA, PA and Stanford Community, Shuttle operations, Financing, Logistics Improved Pedestrian and Bike linkages, between SUMC, SSC, Transit Center and Downtown Palo Alto (includes grade separation, urban design elements and way finding) 22.TDM (Transportation Demand Management) 23.Expand Shuttle System 24.Completion of Charleston/Arastradero Improvements Bol Park Right-of-Way at no cost25.(Currently no cost, could change at end of lease term) 26. Depot and Transit Center Lease at no cost 27.Transit Center Implementation X X X x X x X x X X X X x Updated November 7, 2007 STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST El Camino Real Master Plan streetscape improvement28.implementation, as related to SSC. 29.Adequate and clear roadway access to the Emergency Room, General circulation and Roadway network 30.Residential arterial neighborhood traffic improvements X x X X Provide for exemplary sustainability and green building design to achieve the equivalent of the Leadership in Energy and Environmental Design (LEED) Silver certification for the project. Provide a Waste Reduction & Elimination Plan (including medical32.waste) that meets the City’s goals 33.Mix of uses (to reduce trips, increase walkability, increase TDM, shuttle, and other transportation means) 34.Energy Alternatives (Solar, co-generation, recycled water, water conservation) 35.Reuse of Construction / Demolition / Recycling / Salvage Materials Reuse of existing buildings or Retrofit36.(where applicable) 37.Use of Alternative Fuel for Vehicle Fleets 38.Greenhouse Gas Impacts X X X X X X X X X X X X X X X X Sewer and Water Improvements39.(Review loads on sewer system. Review hardening pipeline from reservoir to new medical center; preferably maintain pipeline, but may upgrade.) 40.Reliability of Electric Utilities (May need to construct second set of cables while existing and new Updated November 7, 2007 4 x x X STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST hospitals are both operational.) Construction of a co-generation plant, and its expansion, or the41.construction of a second plant. Flood Control improvements for San Francisquito Creek, including42.consideration of improvements at Hopkins Park. 43.Equipment needed to address taller buildings, eg. fire trucks 44.Other city of Palo Alto services that may be identified in the EIR 45.No cost leases for substation sites within the research park at the end of lease terms. 46.Construction Fees; Building Permit Fees 47.Transportation Impact Fee 48.Housing Fee (hospitals currently exempt) 49.Impact Fees (Utilities, Others) 50.Payment timing of fees; Payment calculation; Vesting of fees Sales and Use Taxes51. 52.Projected timing for increases in revenue Joint Purchasing / Out-of-State Use Tax Impacts53.(SUMC to use tax license for major purchases) 54.Potential Impacts on downtown retail 55.Payments in lieu of property taxes for additional land taken off tax rolls X x X X X X X X X X X X X X X X X X X X X X 56.Tenant Mix: Retail; Relationship to downtown retail; Restaurants;XPersonal Services; Hotel. 57.Viability, Size, Product Type X 58.Transient Occupancy Tax Revenue X 59.Location / Placement of Hotel X Updated November 7, 2007 Attachment B STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST COMMENTS FROM 11 / 14/07 PLANNING & TRANSPORTATION COMMISSION (Notes in italics are expansions/clarifications, items in bold are suggested additional issues) Land Use A. 1. 2. o 12. o F. o Housing H. 18. & Open Space Community Facilities Parks ¯Add: open space and permeability (Holman) Libraries, Community Centers ¯Add: Public Safety Building (Holman) ¯Add: Day Care Facilities (Lippert) Schools School System Capacity ¯Add: and other impacts (Burt) ¯Add: available land for schools and playing fields (Holman) Open Space / Scenic Vistas Additional Open Space protection for areas not controlled by hospitals ¯ Add: X in SSC (Holman) Transfer of development rights for foothill preservation ¯Add: and historic preservation (Lippert) ¯Add: X in SSC (Holman) Timeline for open space preservation ¯ Add: X in SSC (Holman) Urban Design Height (vs. open space) ¯Add: vs. FAR (Keller) Hotel location and size ¯Add: X in SSC (Garber) Historic Preservation (Hoover Pavilion, Stone Building, Governor’s Lane) ¯ Add: and TDR (Lippert) Add: Transportation systems and linkages (Holman) Ancillary Facilities Services adjacent/within Stanford West, Oak Creek Apartments ¯ Add: and within SSC and SUMC (Holman) Hospital Design Surge capacity during emergencies ¯ Add: and assurance for continued, long-term capacity (Burr) Add: Nonresidential development cap (Keller) Housing Needs Identification of Sites (County & City locations; Zoning Issues) ¯Add: Intermodal housing site (Keller) ¯Add: Address ABAG housing allocation (Garber) ¯Add: Affordable Housing for Nurses (Keller) Palo Alto Intermodal Transit Center Updated October 30, 2007 1 STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST COMMENTS FROM 11 / 14/07 PLANNING & TRANSPORTATION COMMISSION (Notes in italics are expansions/clarifications, items in bold are suggested additional issues) ¯Delete (Keller & Holman) - redundant with #18 19. Housing Site ¯Delete: (Keller & Holman) - redundant with #18 Transportation & Linkages J. Traffic / Air Quality I Circulation Improvements ¯ Delete: Term "Traffic" (Garber) 20. Expansion, Integration, Coordination between VTA, PA and Stanford Community, Shuttle operations, Financing, Logistics ¯Add: SSC (Sandas) ¯Add: Caltrain and School District (Holman) 21. Improved Pedestrian and Bike linkages, between SUMC, SSC, Transit Center, Downtown Palo Alto (includes grade separation, urban design elements and way finding) ¯Add: Town and Country Village (Holman) Add: Linkages (Garber) ¯Add: Linkages to neighborhoods (Sandas) ¯Add: Linkages throughout major portions of the City (Keller) K.Transportation Improvements 23.Expand Shuttle System ¯Add: from (place) to (place) and from (when) to (when) (Holman) ¯Add: to East Palo Alto (Burt) 26.Depot and Transit Center Lease at no cost ¯ Add: X in SSC (Holman) 27. Transit Center Implementation ¯ Add: X in SSC (Holman & Burt) 29. Adequate and clear roadway access to the Emergency Room, General circulation and Roadway network. ¯Add: Emergency vehicles to stay on arterial routes (Lippert) 30. Residential arterial neighborhood traffic improvements. ¯ Add: Emergency vehicles to stay on arterial routes (Lippert) o o o o o o o Add: Smart signals (Burt) Add: Expand TDM to a larger population (Keller) Add: Relocation of traffic signal at PAMF to Encina (Burt) Add: AB 32 implementation (Butt & Keller) Add: Audit of mitigation on a regular basis (Holman) Add: Additional improvements throughout Palo Alto (Garber) Add: No net new trips. Transferable traffic credits (Keller) Sustainability Environmental Sustainability o o o Add: LEED, above Silver (Garber) Add: Certification, not equivalent design (Keller) Add: Long term maintenance and operations included in design evaluations (Lippert) 38. Greenhouse Gas Impacts ¯ Add: AB 32 Implementation, No new GHG (Keller) Updated October 30, 2007 STANFORD UNIVERSITY MEDICAL CENTER AND STANFORD SHOPPING CENTER ISSUE & COMMUNITY BENEFITS & MITIGATION LIST COMMENTS FROM 11 / 14/07 PLANNING & TRANSPORTATION COMMISSION (Notes in italics are expansions/clarifications, items in bold are suggested additional issues) ¯Add: Net present value of clean energy sources. Mandate implementation at a projected year, 2020 (Burt) ¯Add: Use of geothermal energy, where feasible (Holman) ¯Add: Monitoring program to evaluate impacts from employees (Holman) ¯Add: Consider co-op for energy (Garber) ¯Add: No impact on EPA designated Green Power status (Lippert) Utilities & M. 39. o o City Services Public Infrastructure: Benefits & Improvements Sewer and Water Improvements ¯Add: reliability and capacity (Garbed ¯Add: Use gray water (Garbed ¯Add: Water supply lines to be constructed to withstand an earthquake (Keller) ¯Add: Emergency power supply to be adequate in an earthquake (Keller) Add: No net increase in water use (Keller) Add: Water reduction requirements (Burt) Fiscal Q. 50. O O To Project Fees (Permits and Impact Fees) Payment timing of fees; Payment calculation; Vesting of fees ¯ Delete: vesting (Holman) Fiscal Impacts Potential Impacts on downtown retail ¯ Add: Town and Country Village (Holman) Add: Costs for public services (Keller) Add: Mitigations for impacts instead of financial contributions, where feasible (Burt & Holman) Hotel Location / Placement of Hotel ¯ Add: Hoover Pavilion site (Holman) Updated October 30, 2007 3 Attachment C 1 2 3 4 5 6 7 8 9 l0 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Planning and Transportation Commission Verbatim Minutes November 14, 2007 DRA FT EXCERP T NEW B USINESS Public Hearings: Project Review of Stanford Medical Center and Shopping Center: Project update and review of community input related to key issues, mitigation approaches, and community benefits for the Stanford University Medical Center and Shopping Center Expansion projects, and status on environmental and entitlement reviews. Mr. Steven Turner, Senior Planner: Thank you very much, good evening Commissioners. Staff is requesting that the Commission focus on three areas tonight. 1 am going to be going over those three items. One is the Issues List that is contained in your Staff Report. The second is that the Commission is going to hear from our hospital peer reviewer regarding her preliminary findings regarding the hospital’s project. Then third you will hear from Staff regarding just an overall project update and we would certainly entertain any questions from the Commissioners about those three items. Starting off with the Issues List this is really the main thrust for tonight’s meeting. In your Staff Report in Attachment A you will find the Issues List. The Issues List is essentially a very broad set of comments and thoughts that have been obtained throughout the review process from the community, from City Staff, and from the applicants about what should be considered during the Development Agreement and Environmental Impact review process. The Issues List is different from the EIR scoping list. As you will recall, in September the Commission provided comments to Staff regarding scoping comments about those items that should be considered or reviewed as part of the Environmental Impact Report. This Issues List is a much broader list that encompasses issues, community benefits, and mitigations. So it will help Staff, it will be used as a tool throughout the negotiations for the Development Agreement as well as for the Environmental Impact Report. So whereas the EIR scoping comments were really focused on analyzing environmental issues this Issues List is very, very broad and it is intended to encompass a wide variety of topics. Those topic areas, as you will see in the list, are Land Use and Open Space, Housing, Transportation and Linkages, Sustainability, Utilities and City Services, and Fiscal issues. You will also see within the list that the relevant key Area Plan objectives have been placed next to the appropriate topics. These will help to frame the City’s objectives with regard to those applicable topics. The Issues List also contains notations as to which project the issues might or might not apply. Again, we see it really as a tool to help us organize our discussions for negotiation of the Development Agreement and as we review the Environmental Impact Report. Page 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 This is not a final list. This is simply a list of items that we have heard thus far. So we are asking the Commission to provide Staff with your thoughts on the adequacy of this list and certainly we would entertain any sort of questions or modifications or revisions to this list from you this evening. With regard to one particular topic, the Housing topic in the Issues List and the identification of housing sites in the Issues List under Housing one of the issues that we wanted to look at are identification of housing sites. To help you along and members of the public along in the Staff Report there is a brief couple of paragraphs about a summary of the overall housing sites that we have identified so far in the Area Plan and applicable sites through Stanford’s General Use Permit. We have provided that information to you in the Staff Report and also in a map that is attached to the report that shows the relationship of the project site to the four potential housing sites identified in the Area Plan and the broader General Use Permit housing sites. So certainly we want to hear from the Commission about the adequacy of that as well as of the information on the list. The second part of this meeting tonight is to hear from our hospital peer reviewer, Marlene Berkoff. She has been working for approximately the past six months to assess Stanford’s rationale behind the proposals for the hospital projects and to the extent in which the hospital projects fall within the norms of current hospital planning, design, and construction. The Commission has not heard from Marlene Berkoffyet. She has presented kind of an overview of her studies at the Council meeting a number of months ago but this will be the first time that Marlene presents to the Commission tonight and she will be presenting her preliminary findings. A summary of her report as well as the entire report is contained within your Staff Report as well. Thirdly, Staff wanted to provide a project update to you with regards to how the project has been progressing almost now ten months since the applicants made their initial presentation to Council. Most recently, on the urging of the Commission, Staff and the Commission have hosted three community meetings in which Staff and the Commission solicited comments from the community on specific topics. We have had three meetings, the first meeting was focusing on land use and housing, the second meeting was on sustainability and open space, and the third meeting was on transportation and linkages. Approximately ten to 15 members of the community attended each meeting and the intent of those meetings were to introduce issues related to those topics but open it up for broad general discussion surrounding each specific topic. We have summarized the input at each of those meetings into the Staff Report in your attachments. We are also in the process of hiring our Urban Design Review Consultant and that person is Bruce Fukuji. Bruce is known locally as well as throughout the country with his work on urban design issues. Locally within Palo Alto he was a part of the Downtown Design Review Committee in the 1980s and was also a part of the Dream Team looking at the inter-modal transit station. Most recently he was working with Redwood City on the design of Sequoia Hospital and their modernization and expansion project. Bruce has also worked throughout the country on other large developments. What Bruce will be doing for us is looking at the proposals and providing design review assistance to the Page 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 City. He is really going to be taking a look at the project site plans, how land uses and connectivity issues relate to each other, he is going to be taking a look at the linkages between the two projects as well as the Downtown area, the transit center, Town & Country and the surrounding areas. He is also going to assist Staff with the review of general massing and architecture and overall general design. So he will be assisting as Staff in that way as well as assisting the Architectural Review Board in providing peer review services to them as well. Second of all is our work on the EIR and that has been progressing since the middle of the year when we hired EIP Associates, our consultants for preparing the EIR. Currently we are meeting regularly with City Staff, the environmental consultant, and the applicants to discuss issues, to give updates on the review of studies that are being prepared, and to map out our progress for the next year for the deliverables of administrative Draft EIRs and finally a Draft EIR, which would be coming in the middle of the year. So we are working very hard on some key studies including traffic analysis, housing needs analysis, and water supply assessment. We will be getting drafts of those documents early next year, which we folded into the administrative Draft EIRs, which are reviewed internally and that will lead to the Draft EIR being distributed and released in the middle of the year approximately June to July. That leads into the project timeline. The Staff Report also contains an updated project timeline. You will see on the timeline that Staff has entered in dates for those milestones that we have already passed as well as general timelines for the remaining activities. The way that this timeline differs from the previous timeline essentially is that the development of the EIR has been pushed out a little bit farther than what we had originally intended. This is to accommodate the various studies that are being completed. We originally thought that we would have a Draft EIR released to the public sometime in the middle of spring, approximately April to May, but it now appears that draft document will be released in late June to July. After the Draft EIR we will be holding meetings with the Planning Commission and the City Council for review of the projects. It tentatively looks like we will be holding those meetings late in the year and early into January of 2009. The other issue that we wanted to bring up that are contained in your Staff Report is community practitioners. We have heard a lot of comments from members of the community as well as from the Commission and the Council regarding the status of community practitioners that are currently practicing on the campus and their status once these projects are moving forward. Stanford has provided a memo relating their intent for providing space to community practitioners not only through this project but also through space that has been recently obtained in Menlo Park. They are under the impression they are providing the needed space for community practitioners. You can read that memo in your Staff Report as an attachment. That concludes my portion of the Staff Report. I believe Curtis may have some updates for you and then we will move into the presentation from Marlene Berkoff. Page 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Mr. Curtis Williams, Assistant Director: Before Marlene makes her presentation I did want to follow up on a couple of things. One is that Commissioner Keller provided a few questions and also provided some for Marlene but she will respond to the ones that related specifically to that or a combination of us will respond when she is done. Perhaps her presentation will respond to some of those in any event. One of the questions Commissioner Keller asked was relative to the Comprehensive Plan Policy L-8, which limits the City to a little more than 3.0 million square feet of new nonresidential development since 1989. That is an issue we are continuing to look at. We have good numbers since 1998 that indicate that we had about 850,000 square feet or something like that. We have actually had reductions in the last couple of years, net reductions, because we have taken some nonresidential out of play that has turned to residential. We feel like there is a lot of room still left in there but that is something that specifically will be looked at in the Comprehensive Plan Consistency section of the EIR and the Population/Housing/Employment section of the EIR. So we will work on them to come up with that and get some good numbers but we don’t have that right now and also roll under our data guru who is on vacation for two weeks so I couldn’t rely on him today. Second is the trade-off of a lower height that would expand the area taken by the building. We have not calculated specifically how much additional land would be required to be allocated under existing zoning but we are glad to sort of put that into the mix as far as something that we can look at. I think we are probably going to be looking at it as part of the height and open space analysis in the EIR and apart from the EIR as well to try to see what that relates to. Then the other part of your question was if Stanford were to allocate that amount of land instead to a public purpose what might that be? So we are interested in hearing what you think that might be. At this point in time we don’t have any specifics. Open space was essentially the trade-off we saw initially. Thirdly is any guidance about guidelines considering greenhouse gas pollution in the EIR and planning process. I think you know this is an evolving art on almost a daily basis. We have had discussions with the EIR consultant and I don’t know if Cara feels any more comfortable than I do to tell you that right now we are not sure exactly what the methodology is going to be but there will be some attempt to quantify levels of carbon emissions and that will be part of probably the Air Quality section of the report but we don’t have the specifics of what that methodology will be at and we are still working on that with the EIR consultant. As far as trips to Stanford Medical Center and to the Shopping Center and where they originate, you noted that we have some information regarding zip code, maybe employees versus visitors, shoppers, patients. Do we have it segmented by mode of transport? I assume comparable to the Census where we break it out by single occupancy vehicle, transit, pedestrian, and bicycle that kind of breakdown. I don’t think we do but 1 am not sure and we are going to have to check with Stanford to see if they keep track of that kind of information. Maybe later in the meeting one of them can respond to whether they think they have the information broken out in that way. Page 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Then a list from Stanford of the Transportation Demand Management programs and who it applies to. We have not had a chance to work with Stanford on making comparisons on the list of 12 different categories of faculty, staff, etc. that it might apply to but we have provided you tonight with a list of the programs that they currently make available to the hospital. So as a starting point just so you are aware, and those are not made available to the Shopping Center but they are made available to the hospital and Medical Center area. So we will be looking at it in terms of developing Transportation Demand Management approach, more specifically at who it relates to and what is possible not only for the Medical Center area but the Shopping Center as well. Currently ! think your last four categories had to do with Shopping Center and that is not covered currently. So that is sort of a status of where things are right now. With that ! think we would like to have Marlene Berkoffmake a presentation. We have asked her to keep the presentation to 15 or 20 minutes and leave plenty of time for you to have questions and then we can get back to discussing the issues list and those other items. Marlene has, as Steven mentioned, accumulated quite a bit of data from the Medical Center and formulated some preliminary findings that are in her report to you. She continues to get more and more data and will be updating the report as she does. With that ! will go ahead and turn it over to her. Ms. Marlene Berkoff, Peer Review Consultant: I have an awful lot of information, much more than l can go down efficiently in 15 minutes. So while I have a lot of slides I am going to zoom through them and you can ask questions in detail as we go back into the question period. Chair Holman: Perhaps ifl might, if you could be a little bit closer to the mike I think it might transcribe better. Ms. Berkoff: Is that working now? Chair Holman: Thank you very much. Ms. Berkoff: Sure, okay. The purpose of the meeting, as you know it is to review the preliminary findings and in particular to discuss both the need for the projects in the first place and the magnitude of the projects as they compare to other peer institutions and to healthcare planning practices in today’s world. Let’s go to the Disclaimer, Steve. I am not focusing on the seismic retrofit that would be necessary or that is triggering the replacement of the main Stanford Hospital. ! think you all know about that and right now that is not the focus of my report so I am skipping by that. So the Need for the Projects. Aside from the seismic codes there are a few key factors driving the need. One is the number of patient beds, the additional number of patient beds that are required. A subset of that, almost as important, is the fact that the beds are Page 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 going to be private single beds or rooms as opposed to double rooms where most of them are housed right now. Secondly, there is an enormous amount of functional obsolescence, and lastly there are infrastructure improvements that are drastically needed both of them to handle the kinds of equipment, computers, all kinds of medical technologies that exist today. The bed numbers were something that had been discussed a lot. These numbers are in my report, they are in Stanford’s EIR application so I am not going to dwell on those other than to say there is across the board approximately a 35 percent increase in beds that are being proposed for the two hospitals together, slightly different between the Stanford Hospital and Clinics and the Packard Children’s Hospital but not substantial. The source of the need for those bed increases is something that has occasioned a great deal of discussion. There are many ways that Stanford looked at coming about their numbers. ! will run through quickly what some of them are. They have done in depth internal analysis with individual departments with their strategic planning departments and then they have had a number of outside consultants come in and there are two different levels for the two different hospitals both planning consultants and then architects/planners who have reviewed, so there are a number of layers of due diligence. Without my doing the analysis myself which is months of work it seems that they have done this in a very thorough and accepted kind of manner. They have used reputable consultants at numerous levels. They have documented, and again this comes from their census I have no way of validating except to get their numbers, that they are turning patients away in pretty substantial numbers. By turning them away, I know there is a question about this, they don’t come to the door and get turned away. A large proportion of their patients for both hospitals are referrals. People call with a very complex case and ask if you have a bed for patient so-and-so. If they don’t have a bed they don’t accept the patients. An emergency that arrives at the door they will accept, an emergency that is called in if they don’t have the bed they won’t take them. The reason is primarily lack of beds not lack of staff and particularly critical care beds. Their occupancy right now is running close to 90 percent. That is very, very high in the hospital world they normally run at 70 or 75, 80 is considered good, 90 is considered no wiggle room, a bad flue epidemic can put them in trouble in that case. The factors that are impacting beds needs are myriad. One of them of course is demographics and people think immediately of an increase in population. Well, yes there is that, but it is more that the distribution of the population. The over 65 proportion of the population is increasing dramatically and is projected to increase hugely in the next 30 to 40 years. That proportion of the population, the baby boomers, one of the reports I referred to which is not a Stanford report states that they use four times as much healthcare as people in the younger age groups. Whether the four times is correct or not what we have is a proportion of the population using much more healthcare and the over 85 component of them is living longer obviously and they have multi-system failures, they have more repeat hospitalizations, which goes onto the next slide which is the Heath Status. Page 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 As more and more people are living longer and longer, and I hate to say it this way but people who would have died don’t. We now can treat them. So they continue to come back to the hospital and they continue to come back with multiple diseases and overlapping conditions. So that more and more a courtinary care hospital like Stanford or Packard is getting these people. This is impacting the children as well because many children didn’t used to make it through cancer and other dire diseases and they are now and there are greater incidents of diabetes and so forth but those are the primary reasons. There are some other factors I am calling it pent up demand. Both of these hospitals were planned respectively the adult hospital 25 years ago, the children’s hospital 20 years ago. So we are not just looking at a forecast from today we are looking at a forecast that started a quarter of a century ago and now we have some catch up to do as well as looking to the future. So that is a significant factor. There have been a number of regional hospital closures over the past ten years or so, which has added to the pressure now to make up the difference. There is an increased focus on disaster preparedness, something we all knew about before but nobody focused on very much. That has become much more a concern now that any regional hospital that is knocked out of operation others may need to pick up the slack. So the conclusion about the bed need is from everything I have looked at without having been personally involved in doing the analysis myself it seems that Stanford has done their due diligence, that the demographic data and independent studies do support what they are saying, and whether they need exactly 104 additional beds or it is 100 or 99 ! can’t say but the orders of magnitudes make sense from what ! have been able to determine. So let’s move onto the next issue of comparing with peer institutions. Whether we accept or not the bed increases now let’s look at the sizes of spaces that this is implying. 1 looked at a number of peer institutions and ! also got information from a number of other sources. I am just naming a few here and I did not get all data from all institutions because many people just don’t keep the data, don’t want to share the data, and we are sort of asking them for their assistance in this. I looked at UCSF plans for Mission Bay, UCLA, which is the Ronald Regan Hospital, which is a recently constructed hospital, CPMC in the city, Valley Medical Center in San Jose, San Francisco General. I did get a lot of data from Kaiser, which is interesting because Kaiser is a community hospital, not an academic teaching hospital and they are more the Chevy as opposed to the Cadillac and people will think that Stanford is trying to be the Cadillac. Stanford ends up comparing quite reasonably with Kaiser, which is an interesting observation to come to. I also got some data from consulting colleagues of mine, architects or planners who gave me information about recently planned developments at University of Michigan, at Johns Hopkins, I don’t think I mentioned it Northwestern, Duke, you can read up there but a number of pretty comparable peer institutions. With that background the first factor I looked at was the conversion from double patient rooms to all single private rooms. This has a huge space impact and a huge implication. It turns out this is basically the industry standard. Not one single consulting firm that ! Page 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 talked to is planning for anything other than single patient rooms in new developments. In existing facilities sometimes you can’t manage to do a conversion that works but in new facilities this is what is going on. The American Institute of Architects has published a series of guidelines the recent ones 2006 are out now. Many states have adopted them as their code so they are required. California has not done so but is in the process of considering doing so. They say they are going to do it in 2008. There is no guarantee they will so right now if you ask me is it required in California? No it is not but it is likely to go that way. Many other states, the highly populated ones like New York and Illinois, are also going in that direction. As I say I couldn’t find a single example of a recently, not just my colleagues and planning firms, but actually planned or built hospitals like UCLA they all have single private patient rooms. The reasons are major reductions in nosocomial infections as air born hospital contracted infections, reduction inpatient transfers. You can’t put mixed genders or diseases or even substantially mixed ages or conditions in the same room. So in the past with double rooms there were alot of transfers taking place. Two things happened that were negative with those. One was patient falls and that leads to both patient injuries and potential lawsuits and so forth, and also increasing number of nurse and staff injuries of moving patients. Again, ! hate to say it but as people have gotten heavier that is becoming a bigger problem. If you have single rooms you can have higher occupancy rates because you put a person in a room and they can stay in the room and you don’t need to transfer them around or move. How many people have seen two bedded rooms with only one person in the room? It happens lots of times. With all single rooms you do away with that. So there has been a lot of what is called evidence-based design research. I can’t guarantee you that it is correct but this is what is being done across the nation. It would not be reasonable for Stanford to plan a new hospital that doesn’t do this. That is basically what it comes down to. So then we look at what are the sizes of the patient rooms. By the very nature if it is a private room it is going to be bigger than a double room because you need the same amount of circulation space but you have one bed in it instead of two. So the sizes are bigger for that reason. Also you no longer have shared toilet rooms and so that is an additional amount of space. Furthermore, the ADA handicapped requirements which used to be ten percent of a given unit, well there are so many transfers occasioned by having somebody in a non-handicapped toilet room as opposed to one that was, the rooms themselves are not the problem it is the toilet rooms, almost all hospital design today is making all patient toilet rooms large enough so that a wheelchair can get in. These all add to the amount of space. I did get some information, it is in the EIR application that I hadn’t focused on before, but all of the amount of new space that is being added, additional space that is being added to the two hospitals, approximately 37 percent of that amount is due only to the need to converting existing number of beds, not new beds, existing number of beds from doubles to singles. That total comes to over 400,000 square feet is necessary to just take doubles and turn them into singles with no addition of extra beds. This is not total square footage but this is an impact that is very major. Page 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 My conclusion on patient bed rooms is that what Stanford is doing is - I guess I didn’t say one other thing that I should mention. I did compare the sizes of the patient bed rooms with specific data from a number of sources from a couple of nationally published studies and some data from Kaiser and what data I could get from individual hospitals, the actual room size is around 300 square feet including the toilet room and the internal circulation give or take a small amount, five percent or maybe at the top end ten, Stanford was comparable to all of those norms including Kaiser’s norms. So I conclude that they have done a reasonable job again on the size of the rooms and the fact of making them private as opposed to doubles and multi-bed wards don’t exist any more. I looked at three other hospital areas that are big users of space and that also are significantly impacted by the new hospital proposals. I looked at operating suites, the emergency department, and the imaging department. I can go through the litany on each one but in the interest of time I won’t. ! will sum it up by saying every one of them is just overtaken by complex new kinds of technologies and equipment. Anybody who has been in an OR recently knows there are separate computer rooms, there are separate pieces of equipment that never were in the operating room before and now you have imaging equipment morphing into the OR setting, etc. The space needs have really, really grown. In addition, like in the emergency room privacy needs, HIPA regulations the Health Insurance Portability Act, but also the things you sign when you go to your doctor, having private rooms instead of patients lined up in curtained cubicles is no longer the way that things are being done. When ! say ’things are being done’ ! mean comparing across numerous hospitals and peer institutions. So between the proliferation of equipment, the need to accommodate the new technologies, the need to plan for space for future as yet unknown things to allow a little bit of latitude for what may come, and the infrastructure to support it ! think the sizes and the demands of these kinds of highly technical space are reflected in the space that Stanford has proposed for them and they are not out of line when I compare them room-by-room with these peer institutions or the Kaiser kinds of data. So that is a conclusion about all of these space drivers that Steven and I are going to put through. I will mention one other thing with regard to space, which is offsite services. Stanford has already offioaded from the main campus all of what are code defined non-essential services. Those are things like accounting, finance, data processing, human resources, certain amounts of administration, some administration is mandated to stay with the main hospital building. They have already gotten warehousing, bulk storage, and so forth in separate locations. Some is at Page Mill Road they will have to answer where some of the rest is located. It all amounts to about 200,000 square feet that is all offsite and there is no intent to bring it back. Chair Holman: Marlene, just to inform you the reason your light came on was not to limit you but just to help pace you. Ms. Berkoff: Is this about 15 minutes? Page 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: We are just a few seconds from 20 minutes. Ms. Berkoff: So I am going to skip right through to the building heights then. Chair Holman: Again, not intended to limit you but just to help pace. Ms. Berkoff: Okay. As you can see there are many, many reasons why and you can ask lots of questions about specific areas of growth but this is happening across the country. Hospitals are ballooning and it is a serious problem not just for communities where there is an impact but also for paying for it. So building heights, building size. Two factors, one is floor-to-floor heights. The summary on that is quite simply that the need for equipment both in California for the seismic mounting of heavy imaging equipment, booms for slings and other kinds of movable equipment, and the space for infrastructure between floors has led to an increase in the height of slab-to-slab structure. Those nursing units where the beds are used to be maybe 13 or 14 feet high now I have found again many recent developments where it is 16 feet. The diagnostic and treatment spaces where there are operating rooms, imaging, and emergency those high-tech services are typically now 18 to 20 feet in slab-to-slab height. It is not the ceiling that you see it is the structure. So right offthe bat what that mandates is if you have even got a three-story building and you stack up the three floors you are pretty close to 50 feet or even over the top of 50 feet if you have one layer of a diagnostic floor and a couple layers of nursing floors, you are over 50 feet with just a three-story building. So what about the configuration of the concepts that Stanford is proposing? First I want to point out the two hospitals are very different. The adult hospital is a replacement and basically an all new hospital. It does not have 100 percent everything but it has most of it in it. A whole new hospital and that is designed in a way or proposed in a way that is the most ethicacious in use of the site as well as the functional relationship with facilities within the hospital. The Children’s hospital conversely is not a stacked up hospital with nursing units on top of a diagnostic and treatment base. It is four stories of nursing floors side-by-side with the existing hospital. The reasons are that for the adult hospital they are basically replacing the whole thing, doing it from scratch, and they are not trying to keep the old building. It is mostly going to be demolished or converted to other uses. With the Children’s Hospital they are keeping the existing building so they want to attach to it. As you probably know, in California you can’t typically build on top of something and with the Children’s Hospital even if you did it would put it over 50 feet. It is right at 50 feet right now. So going back to the adult hospital which I am calling a ’stacked configuration.’ It is a very common configuration. Again, this has not been scientifically researched effort but I have checked with hospitals across the country and consultants who have designed them and ones that I know personally. Any hospital of about 300 give or take beds I haven’t found a single one that doesn’t have some variation of a stacked configuration with diagnostic stuffbelow on the lower levels, one or two stories, at CSF it is even three Page 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 stories, and nursing units on top. It is an efficient circulation system, it limits outside access, it prevents longer travel distance for patient travels, it limits exposure to infection, and so forth. There are a lot of very good functional planning reasons for it but for Stanford the real bottom line I think is, and ! have not conferred with them about this, is that if you look at the site plan, and as an architect I looked at it I don’t see how they could spread it out much more horizontally. They could spread it out a little bit more horizontally perhaps. I mean I haven’t done the studies. I am not privy to that. To get in the space proposed they are requiring a seven-story stack, which is about as tightly configured in the plans as one could expect at this stage in design. So if it were to get much lower it is like taking a layer cake and putting it side-by-side you can begin to see even if you cut back the space it could easily take double the site area. We have all probably seen site plans it would be very difficult to figure how you could fit it on the site, keep the existing hospital in operation at the same time because you can’t empty it out, tear it down, and then come back, still have service, have a construction staging area, emergency access, and all the things that are needed. So my own personal deduction is I think it would be very difficult for the adult hospital to be in a substantially different configuration but ! don’t know that for a fact. So this is an observation but I think the site area limitations are driving that configuration. At the Packard Children’s Hospital site are limitation is also driving the decision that the need to keep the existing hospital and keep it in operation says they have to have the space adjacent to it and there is not much site are adjacent to it. So they have squeezed in primarily it is nursing units that they are adding. They have stacked them up side-by-side with the existing building connected on the lower levels because the newer heights are higher than the old height even at that hospital which is only 20 years old. So they both have different configurations and my judgrnent is that while they both have done their best to do a functionally good plan what is driving it is really the site limitations and the need to keep both hospitals in operation until the new space is built and they can phase into it. I think that concludes what I have said and I will be happy to try to answer questions on this complexity. Thank you. Chair Holman: Thank you. Commissioners, if we have questions for Marlene this would be the time to ask them. I also don’t want to preclude anybody from the public from speaking either if anyone has to leave. I currently have only six cards from members of the public. If anyone else wants to speak if you would turn a card in. Seeing no one raise their hand that they need to leave immediately then Commissioners let’s ask questions of Marlene. Commissioner Garber. Vice-Chair Garber: Marlene in the planning tasks that the hospital undertook in interviewing its business units, its various medical units, etc. what was the planning horizon that they were using? Page 11 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Ms. Berkoff: Ten years which is not really all that far. As far as I know it was ten years to 2016, which is not even exactly ten years any longer. It was when they started. Vice-Chair Garber: How does that compare to some of the other studies that you may have participated in or other benchmarks? Ms. Berkoff: It is pretty standard. Many people who start planning look at even closer horizons which I am always advising them not to. A common problem is that when it starts people look ten years out but by the time they get through some of their planning iterations it is no longer ten years away. I think outside of the population growth statistics, which they have looked at further, the stated planning horizons I believe are about ten years. Vice-Chair Garber: Presumably the design lifespan for a building is significantly beyond that. Ms. Berkoff: Right. Vice-Chair Garber: What are some of the strategies that Stanford should be employing to bridge the gap between the ten-year and a potential 20 or 30 years out beyond that? Ms. Berkoff: It is a very valid question and it is almost a balance between being able to really demonstrate what you need now versus projecting out into the future. We all know how inaccurate that can be. When they do for instance the bed number projections they will look at a range of bed numbers, a low, a medium, and a high. You can still say it is a ten-year projection but if you look towards the higher end and if you look towards the medical developments and so forth you don’t accept the lowest of the low numbers that you get from different analyses. Other things that they are doing for instance with the operating suites is they are planning for a couple of, I think it is one or two it might be two I would have to check the numbers, additional operating rooms that they don’t have fully designated for they are calling it ’future technologies,’ and they are big hunks of space, it is 1,000 square feet each. Whereas an operating room by itself these days plus its support of computers might be 650 to 800 square feet. So they have a couple of places built in. They have done the same thing with some imaging areas for future technologies. The other thing that happens in the planning process, the physical planning, is you try to surround some of the really high-tech areas with soft spaces that can be kind of taken over as really hard things are required more in the future. Vice-Chair Garber: So then the planning horizon then for the technology is probably less than the ten years? Ms. Berkoff: l don’t really know. Within different departments like imaging people actually do work out a good eight to ten years. If you talk to vendors they will say we don’t know we will build it bigger just in case. In fact, ! think people within the Page 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3o 31 32 33 34 35 36 37 38 39 4O 41 42 43 44 45 46 departments, within the surgery department or within imaging they do have some reasonably good ideas. The trouble is there are counter-veiling forces that are very hard to predict. If you go to an all-electronic medical records system you might save space in one area whereas you need increased space in another. So it is a very tricky business and I am not giving a solid answer. I am afraid it is because ! don’t think there really is one. They may be able to answer that better than I. Chair Holman: Commissioner Lippert. Commissioner Lippert: Following up on space needs and hospital expansion there is also certain technologies that allow for reduction. Part of that is outsourcing of the medical staffthat do certain diagnostic readings and microsurgeries via the Internet. How do those technologies affect square footage? Ms. Berkoff: With regard to microsurgery over the Internet I am afraid that Stanford is one of the kinds of places that people look to tell them how to do it not the place that gets the information so much over the Internet. I don’t honestly know. I know that there is a miniaturization of pieces of equipment. MRIs used to be humungous and built in bunkers underground and now we have them in mobile trailers. Counterbalancing that is the proliferation in items of equipment. I honestly without getting into specific pieces of equipment I don’t know if it has affected them. I have not been able in the kind of review I have been doing to dig deep enough to find out. ! would say in the imaging department or in the surgery department those are the two places where it probably would have the most affect. One thing I just had a recent experience with in a consulting assignment of my own was the impact of computers. People were planning and designing new intensive care nurseries. They take up a lot more space because now you have to have a separate room for each baby whereas they used to be bassinets lined up next to each other and so the space has gotten huger. Nobody had really thought through the fact that now there is a whole spate of monitoring equipment that is needed because no nurse can hear the baby next door when he or she is looking at the baby in front of them. So now there are additional pieces of monitoring equipment at each room, different central station monitoring pieces of equipment, I think there is a theory of unintended consequences ! am afraid operates all the time and I don’t know the detail of how they have gone about addressing that. Commissioner Lippert: As a follow up on that I guess space displacement, are there operations that can be based underground where it is not necessary to have windows for instance or daylight? We saw recently Stanford did an exemplary job with building a multi-story underground parking structure that goes down five or six stories. Is it possible to locate operating theaters and treatment rooms below ground where they would not need to have views? Ms. Berkoff: For some items i~ is. A lot of the things that used to be located in basements are now not in the hospital any more. A lot of the support offices and bulk Page 13 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 warehousing and storage, a lot of that is part of the offsite services. Radiology, imaging kinds of equipment can be. I don’t know the plans in enough detail. I don’t even know if they have been developed in enough detail to know if they have things below grade. Yes, there are number of things that can be where you run into a design issue is if you need a cohesive department and some of the things can be underground but some of them cannot be like offices or areas that require daily use of staff and so you really want to be able to provide some connection with the outside. I don’t know to what extent Stanford has done it. I know they have a full basement planned in the current concept and ! don’t know how many layers below grade they could go to put parking if they needed to. As I recall from some past work, not at Stanford, something at the VA Hospital there is a moderately high water table here I recall. So ! don’t know the answer to that but I suspect they would probably put as much down there as they can. It is a good point to question. Commissioner Lippert: ! have one more question but I will cede to another Commissioner. Chair Holman: Commissioner Sandas. Commissioner Sandas: Thanks. I just have one question for the moment. In your Summary on item J about space part two talks about the impact of proposed increase in number of beds. You say, "However, if the rationale for Stanford’s projected increase in new beds is not deemed supportable, then space needs to be reduced substantially." I am assuming conversely if there need to be more beds than what they are projecting we would have to go the other way. I guess what I would like to know is how can we find out ahead of time if those numbers are supportable or not? Based on your Peer Review it appears that the numbers are supportable so what would let us know that they weren’t? Ms. Berkoff: You know the only way that ! can answer that is that Stanford has done in depth every single thing that any hospital I have ever worked with does to try to come up with forecasting need because it needs forecasting. We don’t know what it is going to be. They have done the analysis from the ground up, from the bottom up, they have done it internally with the individual departments, who are often maybe going over the top and reaching for as much as they can possibly get, maybe gaining thinking well if we ask for X we may get X minus ten, so let’s ask for X, and we really only need X. All of that stuff goes on. Then we looked at it holistically from the strategic business planning point of view. They have looked at it financially because bottom line the two hospitals have to pay for it. They have called in two very respected independent outside firms. They are not the architects so they have no vested interest in the answer if one could attribute an ulterior motive to the architect saying well, if you project more space then we get to build a bigger building, if you want to attribute a venal motive like that. The planning firms have no such motive and Accenture is their firm that did the analysis for the adult hospital and Childress out of Los Angeles did it for the Children’s Hospital. They are both highly respected standard firms in that world. They have national data at their disposal. I don’t know what you could do beyond that. Page 14 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Commissioner Sandas: So what I think I am hearing you say is just like stick with the number that is projected. Ms. Berkoff: I have basis upon which to question it. You could hire yet again another set of consulting firms from the outside and they would probably nit-pick it and I doubt that they would come out with anything substantially different. Chair Holman: Commissioner Keller and then Commissioner Burt. Commissioner Keller: Thank you. I would like to confirm a few things and see if I get it right. Firstly, ! would like to point out that usually we get handouts of the slides. Mr. Williams: We apologize for that. It was late in the day when we got this all put together and the copier machine jammed. So we will get you subsequently copies so you do have that for your records. Commissioner Keller: Thank you. Somehow the colors made it a little hard to read. Ms. Berkoff: In the light here, yes, sorry. Commissioner Keller: So firstly, I would like to understand I think what you said and please confirm this is that ! think that you said a large reason for the design being up versus out is primarily due to the site limitation, secondarily due to the need for continuity of operations, and thirdly due to good functional design. Is that what you said? Ms. Berkoff: That is pretty much correct. Commissioner Keller: Thank you. The second thing is that in term.s of your response to Commissioner Sandas’s question would it be fair to say that your role is sort of like an auditor of the process that you are not repeating the analysis that you are analyzing the process to make sure that the process that the analysis was done under is appropriate. Is that fair? Ms. Berkoff: That is a very good analogy, yes. Commissioner Keller: Okay. So let me probe one little piece of that and that is that there was some calculations done based on the existing conditions. So there are some comments for example Lucile Packard’s Children’s Hospital you say that they turned away so many children who might have been treated, things like that, based on some calculations based on current conditions. What ! am trying to understand is your baseline for that is 257 beds but the current actual physical number of beds is 216 and 41 .of them are under construction. So I am trying to understand to what extent do the 41 beds solve the problem that you have addressed. Page 15 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 Ms. Berkoff: I understand your question. So I probably spoke too fast in saying the analogy as an auditor is correct because I also am doing some investigative reporting let’s call it, which is a little bit different from just auditing. The number of patients turned away who are not accepted, turned away is kind of the wrong expression, they are just not accepted. This is based on the 216 beds because that data is from 2005. Part of the reason that they are now finishing out those additional 41 beds to get up to 257 is that that was planned and the license was approved and so forth. They didn’t initially know if they were going to need them all but as it turns out they did because they are turning patients away in substantial numbers. So that will somewhat ameliorate the need and the bed forecast for the future took those additional beds into account but they did it by the numbers. In other words, there is no data on the ground of turning patients away based on 257 beds because they don’t all exist yet, as you are correct in pointing out. So that is based on the 216 beds. That is not a calculation that is a census fact, documentation that they keep. Commissioner Keller: So what I am wondering is I think actually none of the extra 41 beds are currently occupied. I think the construction of the additional 41 beds is not complete. What I am wondering is would it make more sense for the Children’s Hospital to use 216 as a baseline because that is how many exist and the 257 is sort of a theoretical number that we don’t actually have any real data for. Ms. Berkoff: Yes and no. They don’t have any data that they can say that they turn patients away based on 257 beds because they don’t have that number in their operating census now so you are correct about that. However, when the firms who did the internal analysis, Tardus and Smith Group who reviewed it yet again, when they did their analysis they took as their starting point the patient bed projections not the increment. It is the total number of beds that you need and came up with the 361. So it wasn’t that they said well, let’s wait until we get to 257 and then see how many more we need but rather this is the number that we have theoretically to serve the existing population. It is not as strong an analysis because those additional 41 beds don’t exist at the moment. So we could question them and ask them to go back and say how they accounted for that but essentially they are looking at what the future demand is. If you were building a brand new hospital you would be starting from zero information and you would still be doing a forecast and you would do it the same way. You would look at the total need not the incremental need. The incremental need is a subtraction that comes afterwards. Commissioner Keller: It sort of seems to me like l am sort of getting a raise and before l actually get that raise in my paycheck I am plotting how to get the raise and figuring out how to spend it and to justify it. In some sense it makes more sense to me to base my request based on what 1 already have because those are what I can justify. So it would make more sense to do the calculations based on the existing. Chair Holman: Commissioner Burt. Page 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Commissioner Burt: I wanted to make sure I understood some of the scope and depth of the Peer Review process. First the data for the patients, what was the term you had, not turned away? Ms. Berkoff: Well, they are referrals that are declined. They are declined referrals. Commissioner Burt: Do you have that data? That is something we had talked about wanting to see that. Ms. Berkoff: My only source for that is what Stanford gave me. So I have no different data than you have in the EIR application. Commissioner Burt: Were we given that specific data? I thought at our last meeting we were asking for that data. Ms. Berkoff: There are just a couple of numbers and ! have them in my Summary. Mr. Williams: Stanford very early on provided in terms of letter about the existing sort of justification for the hospital the numbers of what they were turning away. I think what we didn’t have and maybe asked for was you have declined 50 per year is that out of 500 or is that out of 100 that are referred to you. That is what I recall being asked and ! don’t know if we have gotten that number as far as if that is a large percentage that is being declined or if that is a small percentage. Commissioner Burt: If I might clarify, my recollection is that what we didn’t have was any way to correlate that into bed needs. If you talk about a number of patients per year that are declined unless you know the anticipated stay of those patients you can’t even do a calculation of how many beds you are short. So I thought that was part of what we were going to get from the Peer Review. Ms. Berkoff: I did not get that information. There are data on average length of stay so one can determine that. One could also say and they have said this, I don’t have it in writing anywhere, but referrals are typically more serious, higher acuity, more critical cases. They are not just the ordinary kind of case so that you might be able to apply a differential average length of stay. ! can try to get that data. I have not. Commissioner Burt: Second, under your Summary that is in our packet, Attachment E, the second page, first paragraph, it says that it appears that the number of beds etc. and that one of the reasons for an increase in the number of beds is advances in medical treatments and capabilities. So can you explain how the advances in medical treatments cause the need for additional beds? Ms. Berkoff: That one is quite easy. People who have cancer who would have died are kept alive and so they have remissions and then they return. So you see the same patient over and over. As I say, this is particularly true with children. This is true for other kinds Page 17 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 of [terminal] injuries but I think that with oncology it is one of the major factors. Actually heart disease as well. Commissioner Burt: Thank you. Then my next question is really at the core of what I think we were hoping to hear from you through a Peer Review is trying to look at the difference, if there is a difference, between the need that Stanford has and perhaps a want. That is what we were really wanting to understand as one of our key issues, is there a difference between those? What I heard tonight was that you reiterated that they used reputable firms and we certainly would assume that they used reputable firms. It is not only an analysis of meeting the needs of a community but it is also a business plan. Ms. Berkoff: Absolutely. Commissioner Burt: So we haven’t heard anything that helps us separate between what is the need and what is something else that might be above the need if there is a difference between the two. Ms. Berkoff: There certainly is a difference between the two and one encounters it very, very early in planning projects. Usually the difference between need and want comes to light when you start getting cost estimates for what it is going to cost to build the structure. Then people start pulling in their demands. Stanford has already gotten to that point and I believe I saw in there somewhere that from their own experience it is usually possible to cut the program space that is estimated maybe five to ten percent and still keep the same components in the building, without saying okay, we are not going to have outpatient orthopedic clinic here at all anymore we are going to put it totally offsite. Those are medical judgments and those things get into medical judgments because that is not a code requirement. If they can reduce the space by tightening the design and requirements, I am making this up - having a 290 square foot patient room, which is a repetitive element instead of a 310 square foot patient room that adds up. Commissioner Burt: My question wasn’t so much about the square footage per room but the number of beds. Ms. Berkoff: Well, okay, the number of beds I have answered that as best I can. There isn’t any other way that from the outside other than having done the analysis myself and saying what did you use for the low and the medium and the high and really digging into it I think they have done as much due diligence, actually more than many institutions. ! still think there is possibility of tightening the space a little as they go through the design which is something that normally takes place anyway, but other than that I can’t, I am a medical architect but I am not a doctor or hospital administrator, there aren’t any services that I can see that they are including that I can say you don’t need to have. So there isn’t anything there at all that jumps out at me as being just a want as opposed to a need. Chair Holman: I have a follow up question to that and before I go to that Commissioner Lippert I would like an indication from the public. You have come to hear and be heard and ifI could get some indication of members of the public who might need to leave. We Page 18 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 have at least one more round of questions for Marlene from the Commission. So if you all are okay standing pat then that fine, if you are not then I would need to see some indication that you would want to move forward with public comment. So it looks like you are okay hanging pat so another round of Commissioner questions I am guessing is probably another 20 minutes or so. Okay. Why don’t we do one more round of Commissioner questions, we will limit that to 15 minutes and then we will go to members of the public. Then if the Commissioners have more questions, Commissioner Burt? Commissioner Burt: Would it be possible for us to be able to let the public go now and then ask additional questions of Marlene later? Chair Holman: We could, Commissioner Lippert had a follow up. So if Commissioners are okay with that then Commissioner Lippert ask your follow up and then we can go to the public if that is agreeable. Commissioner Lippert: Just in following up on Commissioner Burt’s question here in terms of need versus want. ls it possible to quantify the hospital services in terms of, and I use this very loosely, if you think of them as having patient services they would have the teaching hospital and then there is probably research going on and there are probably more segments. If we were to focus in on those is it possible to quantify the hospital in terms of those distinct areas and say the hospital is this much larger because of research, the hospital is this much larger because of the teaching hospital, the hospital is this much larger because cancer is something that we have a larger population of cancer survivors in the Bay Area versus heart disease? I am just making up these examples. Ms. Berkoff: I think it is extremely difficult to quantify that. I don’t know of any heuristics that absolutely address that. One of the things I do know is that academic teaching hospitals are larger than community hospitals. Colleagues who I have talked with about this, there is no definitive number but they say and I agree with this from my own experience, ten to 15 percent of space maybe closer to ten is a premium that you spend for having an academic teaching hospital as opposed to a general community hospital. That is largely because you have training staff, you have interns and residents, there are more people in rooms at any given time, even inpatient rooms there are the people standing around the beds so you need a little bit of extra space for that. You have the latest greatest kinds of pieces of equipment because they are doing research on those pieces of equipment. You need space for those residents, interns, and training staff, post docs and so forth to hang their coat and write their notes and sleep overnight and so forth. So you do have associated needs like that that are not in community hospitals where the doctor is on call and you call him or her at home, at Stanford they are sleeping there. ! don’t know other than the premium for the academic type of space one of the benefits of having a research hospital, and they call them that a research hospital, a courtinary care hospital, is that they do get clinical trials of new pieces of equipment, of new modalities of care, pharmaceutical people come in, outsiders are there more, visitors are there more, in-service conferences take place more, teaching of community physicians not just full time faculty. It is not just didactive teaching it is at the bedside so they need to be there in the hospital. It is not like they could just go to a conference room somewhere else, Page 19 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 which they do when they have separate conferences. That is the best I can do quantifying it. Chair Holman: Okay, thank you. Curtis. Mr. Williams: I am assuming you are going to go to the public now. Before you do I just want to make a couple of observations. One is just trying to add a little bit to Commissioner Burt’s questions about the number of beds and that aspect of it. I think our hope also was that we could better truth that number but it has become pretty obvious as Marlene has gotten into this that that is -market study isn’t necessarily the phrase to use, but somewhat similar to that and that number one it is a very expensive exercise to get somebody to do that. Number two some of that does rely on business plans and such that are proprietary and there is a limited amount of information that we can really get to do that kind of analysis on our own. So just to put a little context around that. The other thing I wanted to mention and I think for us it has been a big education for us to get Marlene in and understand these things a lot better. She is here tonight to provide information and to get some indication of gaps that you think maybe she can go back and try to fill in. I just didn’t want to lose sight of the fact that the primary purpose tonight is to get to the Issues List and give us some feedback on that. We would be glad to have Marlene come back after she prepares some more of this information and gets closer to a final report and fill in those gaps for you. Ms. Berkoff: Actually, I just wanted to mention one thing. There is a recent publication that just came out in the late summer and fall of this year not done for Stanford or by Stanford. It was actually commissioned by PAMF for their study for their hospital and some other agencies and it was done by the New Century Healthcare Institute. Mr. Williams: For their hospital in San Carlos. Ms. Berkoff: A lot of the population, the demographic data that I mentioned in looking at Stanford’s projections came from that. Although they had done their projections prior to that and it focused on San Mateo and Santa Clara counties. It was an in depth study of healthcare needs in those two counties for acute care in-patient beds. So that is available to the public and it was a good independent resource. Chair Holman: Thank you very much. At this point we will go to members of the public. ! think we probably will have a few more questions for you Marlene if you can stay for a bit. We have 11 cards and two comments here. One is we are going to set the timer for three minutes and not buzz anybody out at that but when the light turns red you know it will be three minutes. Again it is not to preclude you from speaking for five but it is to help pace us. You will hear a buzz at five minutes should you take that long. The other thing is that we are not here to advocate or to recommend against a project. We are here to speak to the item that is on the agenda specifically which is to talk about issues and mitigations and public benefits. So if you could keep your comments focused Page 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 on those that would be most helpful this evening. Given that our first speaker is Shelley Hebert to be followed by Karen Sundback. Ms. Shelley Hebert, Representing Stanford: Good evening. I am the Executive Director for Public Affairs at Stanford Hospital and Clinics. On behalf of the hospital and our partners, Lucile Packard Children’s Hospital and the Stanford School of Medicine, I want to express our appreciation to City Staff for all the work that has been done to reach this point in the process and also thank the Commission for the opportunity to comment tonight. First I would like to address the Peer Review report, which we just heard from Marlene Berkoff. The findings presented this evening validate that the proposed plans for the new Stanford Hospital and the additional bed capacity at Packard Children’s Hospital are within current norms for good planning and modern medical practice in general and for academic medical centers in particular. The extensive information provided in the Peer Review for benchmarking the hospital’s plan against other new hospital projects, tends in medical technology and patient care, and the associated space requirements are of tremendous value. We are very appreciative that this report now provides a greater context for understanding the key drivers for development of healthcare facilities to serve our community in the 21 st Century. Secondly, I would like to comment on the Draft Issues report that will be presented tonight. We will be providing written comments about this list prior to the City Council meeting on November 26. This evening I would like to just make two brief points. First the many of the issues identified on the list are similar or related to ones being evaluated through the Environmental Impact Report process. We look forward to discussing those direct impacts and ways in which they can be mitigated when the Draft EIR is published. We are very concerned however, about a number of issues on the list that have no connection to the hospital projects or our role in providing healthcare services for our community. Examples of these are suggestions that the hospital should provide Charleston/Arastradero roadway improvements, the ballpark right-of-way in the Research Park, or permanent dedication of Foothill lands as open space. The hospital projects have no impact on these issues whatsoever. It really seems to us that it not reasonable for this list to be used as an open ended opportunity to include so many issues unrelated either to the projects or to healthcare just because they are mentioned at some point in the process. We do agree that there are many significant issues directly related to the hospital’s projects and their impacts that must be addressed when the analysis in the Draft EIR is available and we look forward to continuing the process of developing effective solutions to those issues together. Thank you. Chair Holman: Thank you Ms. Hebert. Karen Sundback to be followed by David Schrom. Page 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Ms. Karen Sundback, Palo Alto: I would like to thank Staff for this report, especially Mr. Turner. I wanted to refer to mitigation page three, item 20: I do hope this does relate to the hospital. This relates to transportation. Presently we have no buses between the Medical Center and the Palo Alto neighborhoods. We do anticipate a large number of people joining the hospital. The Marguerite does not venture into neighborhoods. We have several neighbors who work at the Medical Center and would love to keep their cars at home. I think this aligns with most of our philosophy and it is a great way to mitigate traffic. I hope that you can use this opportunity to connect the Medical Center to the Palo Alto neighborhoods with buses. Thank you. Chair Holman: Thank you. David Schrom to be followed by Emily Renzel. Mr. David Schrom, Palo Alto: I look at this project and I think about the changes it would imply for the community and ! am really almost speechless. Maybe you wish were but I do have a few things I want to say. First is that the departure from the zoning being requested is immense. We are talking about closer to a three than a two timed increase in allowable height and that is a huge change. The second thing is we are talki.ng about somewhere between one and two million square feet. I don’t know where to draw the lines between the hotel and shopping center and the hospital and the med school. It is once again a huge increase in what is permitted. As a 35-year resident of the community what I have seen is that we have built in the community and mea culpa, have failed to pay our own way. Well, what do I mean by that? Well I mean the quality of services here, the quality of air, the amount of noise, the things that people care about when you move into a community like this have been degraded. That means that those of us who intensified land use and with it the impacts on our surroundings have effectively stolen from our neighbors who haven’t taken that action. So the gorilla in town the biggest neighbor around decides to come in and ask for something this huge all of us are at terrible risk. It is my hope that the founder’s words, ’dedicated to science for the public good’ will somehow be prominent in the minds of everyone who has anything to do with this on the Stanford side so that we don’t push farther past the point where the benefits of additional intensification of land use are smaller than the costs and all of us suffer public loss in the name of private, and Stanford is a private institution, a private landholder game. So what I am hoping is that Stanford will find a way to hold harmless the rest of the community as a result of what it is doing and that you folks and the City Council will assist them in doing that. The second thing I want to ask for is a science or evidence based planning process. When I look at the timetable I don’t see how you can possibly have that. We need to discover what the real impacts and the real possible mitigations can be and we are not going to do that if the Environmental Impact Report isn’t finalized before people are negotiating the Development Agreement. Just as one thing, leave the counters out. Page 22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Don’t have count days. It is a few thousand dollars worth of equipment. Randomly select the days on which to use the data and that will get around any tendency to manipulate the data with bogus trip reduction. Finally, I think that thecosts of this are going to be felt in our schools. If we put 2,000 new houses and 3,000 new employees in the area it is very likely that our school population will increase by more than ten percent, in our parks and open space, in our roads we are going to have at least 10,000 additional trips including what the residents will generate. In our library and the sewer system and the air quality and the noise and I really feel that it is incumbent upon us to find a way to either make this project be beneficial to Palo Alto or to ask the folks at Stanford to put it someplace else in a community where it will be beneficial. I am willing to look as a Palo Altoan at providing benefit to all human kind because cutting-edge research is being done here and people are coming from all over the world to get treatment they can’t get anywhere else. Having just emerged from a conversation with Paul Earlich I do want to say this, 150,000 people died today. On the one hand that is terrible, if you happen to know one that is even worse. But you know 350,000 were born and that is a big problem. It is conceivable that shutting down the Medical Center would do more good for more people in the long run than making it bigger. Thank you. Chair Holman: Thank you. Emily Renzel to be followed by Tom Jordan. Ms. Emily Renzel, Palo Alto: Chair Holman and members of the Commission I have provided you with some written material and ! see I have a few typos so forgive me I did it in a bit of a hurry. The Stanford University Medical Center and the Stanford Shopping Center projects are proposing a number of exceptions in the Comprehensive Plan and its related zoning. Stanford is also requesting and irrevocable Development Agreement. It seems to me that a threshold question is what rules govern when a project far exceeds the projections in the Comprehensive Plan. Beyond that of course are details of mitigation and public benefits. I think there is a big relationship between the new employment generated, housing, and schools. As I understand the projects they will result in at a minimum of at least 1,500 new jobs mostly for low and moderate-income employees. Since Palo Alto already has a severe shortage of housing for this income group it is reasonable to expect that Stanford should address this need. If into the 1,500 new housing units has two school age children and that is not an unreasonable assumption that would be some 3,000 more kids in the Palo Alto Unified School District that is a lot of grammar schools and/or a lot of portable classrooms using up still more school yard’s playing fields. It is easy to see that there is a very serious domino effect that must be addressed as part of this project. 1 was struck by Table 1 and 2 on page three of the Staff Report. Under the GUP guidelines sites were identified for 3,018 housing units, few if any of which have been built so far. It is anticipated that 2,420 units would be required for the GUP build out. The school district has already deployed portable classrooms on every school site. If even half of the housing sites are developed with two children per household it is clear Page 23 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 that the district will have to reopen all of its closed school sites. Perhaps Stanford should be required to reimburse the school district for utility tax revenue and rental income associated with these closed schools so at least the district will be no worse off for all this new housing. Stanford may need to identify a school site in the north part of its campus area. I will just try to go to the end because I see the yellow light is on and ! have some other things. Chair Holman: The red light indicates three minutes if you need the other two you are welcome to it. Ms. Renzel: I appreciate that. These are such major projects and combined with the GUP are creating a largely unregulated community with huge impacts for Palo Alto. I think it will probably require most if not all of the mitigations and benefits listed in Attachment A to even begin to compensate Palo Alto citizens for these projects, which exceed level in the Comprehensive Plan and zoning. In addition I especially support the items below: One, I think it is time to draw a line for Stanford development above Foothill Expressway and get permanent protection of all open space including Coyote Hill. ! have been around long enough to see expansion after expansion of the Medical Center, the Shopping Center, the takeover of Dwight Way and Welch Road, on and on. I think as we approve these major projects we have to have some assurance that there is some point at which this is going to cease. Two, I think Stanford should make a major contribution to the proposed police and fire facility, which must serve this behemoth development. Three, 1 think Stanford should be required to provide adequate housing for all new low and moderate income employees and it should be required to compensate the Palo Alto Unified School District for reopening all of its elementary schools which I think will be needed. Without complete mitigation and significant benefits this project has the potential to do significant harm to our already stressed quality of life. I think David Schrom spoke eloquently to that. We should not enter into any Development Agreement without addressing each and every impact and without receiving very significant public benefits. Anything less is a recipe for disaster of gridlock, deteriorated schools, fewer playing fields, and continued pressure on our housing market, not to mention serious east-west traffic. Having said all that I would just say that I also go back far enough that I remember the debate over the Palo Alto Medical Foundation Hospital that was proposed between Bryant, Waverley, Channing, and Addison. It was a major hospital and there was at that time a group called the Regional Hospital Facilities Planning Board. It was actually a Page 24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Regional Board appointed by the Governor or somebody who was to look at what each community was doing in terms of hospital facilities so that individual facilities didn’t overshoot their mark. Because at that time the figure was that if you were below 88 percent occupancy you didn’t break even. So if people built too many beds they didn’t break even. ! am sure Stanford is quite aware of that but they draw from a huge region and we don’t even have a sense of what is being built in Arizona, Wyoming, Boston or wherever. Chair Holman: Ms. Renzel it is now five minutes. Ms. Renzel: ! understand. I think that there is a much bigger issue here in terms of both sub-regionally and regionally and nationally in terms of understanding what is our fair share to be done here. Chair Holman: Thank you. Tom Jordan to be followed by Sheri Furman. Mr. Tom Jordan, Palo Alto: I want to speak to what I hope this Commission does. It doesn’t go directly to the points put in front of you which you will vote on and then pass onto the Council. It is vitally important that you think of these things early and we get very few chances to address you as a group. The first area is that I hope you either as a Commission or as individuals, I don’t know the proper procedure but clearly it must be done, communicate to the EIR firm what is the ABAG formula for computing housing allocations based on unit growth and other growth of development. There is no reason for them to have to go figure that out, there is no reason for you in the future to have to figure out did they apply it correctly you already know it. Why don’t you just communicate it to them and say this is the formula and we want you as the EIR firm using this formula to compute what the impacts this project will have on what ABAG is going to be allocating to us. It is something very specific you should do or Staff should do. Don’t wait on Council to do it. Here I must say that for myself and I think many others in the community we consider this Commission the strongest point, the strongest element in the planning process and we want you to take the lead in doing this. It is important that you as people highly respectful of planning do this important actions as I have just described. The second area somewhat along the same lines is for you to communicate to the EIR firm is your own ideas because you can pretty well foresee what the impacts are going to be in general, you may not quantify them exactly but you know in general what they are going to be. No one knows the community better than you and for you to suggest to the EIR firm specific mitigations or modifications. ! think it is completely appropriate. !t is done in trial courts where the trial judge simply looks at the attorney and says I would like to be advised and briefed on the following points. You in a way although you are not the ultimate word you are the advisory body to the Council and it is completely appropriate for you to say these are the things we think would you address them. ! hope you will do that..They simply are not going to have the local knowledge that you do. Those are the two particular examples. Page 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 You might also slightly differently communicate to them that you do not want to see in the report that comes back because you all know from experience that the draft report almost never gets changed. The comments are responded to of course but nothing changes. You do not want to see when they find environmental impacts that need to be changed or reduced or modified that you want to see things with teeth to make that happen. Thank you. Chair Holman: Thank you. Sheri Furman to be followed by Ben Lerner. Ms. Sheri Furman, Palo Alto: Good evening Commissioners. ! am here tonight just to present to you some points to consider. They are going to sound like criticisms but I actually just mean for them to be simply items to be considered. As far as traffic from some of the stuff I have read by project completion outpatient visits to the two hospitals will increase by 29 percent or an extra 597 trips per day. I would like you to consider how do you reconcile those numbers with the no net new trips formula. We have looked at Sand Hill Road and E1 Camino but people coming from 101 will use Embarcadero or University. How will those already congested 25 mile per hour streets bear the additional traffic of the patients, people coming to visit patients? In reality people coming for appointments or to visit are not likely to use a park and ride option. As far as water we haven’t heard much about water but we should also aim for no net new water. How much extra water usage will the Stanford expansion, and when I say Stanford I am talking about a generic for both projects, require and what conservation mitigations are planned? What priority will Stanford have over Palo Alto residents when it comes to water? With water becoming an increasingly scarce resource it is critical that Stanford does its fair share. We have to be careful not to allow the same kinds of priority as far as some of the water resources that we allowed in the Mayfield Development Agreement. Those of you that participated in that probably know what ! am talking about. Then there are greenhouse gases and as Mayor Kishimoto has noted we should also push for at a minimum no net new greenhouse emissions and ask if and how Stanford plans to meet the AB 32 requirement of a 25 percent reduction in greenhouse gas emissions by 2000. Schools have been brought up. The school district is already at capacity. We might consider talking to Stanford about providing for a school, providing land like they do for Paly or by buying some of the acreage say at East Meadow Circle and giving it to Palo Alto for us to build a school where there is need. As far as expansion this touches on what Commissioner Burt was talking about. While the retrofit is mandated it is not clear is the expansion absolutely required or is it simply desired? I would like to know a little more on that. Does Stanford get to keep expanding Page 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 because people are being turned away or not admitted or is there some limit? When will the next expansion be and where will it be? Are we just going to end up with a little cluster of 120-foot buildings in this area? So I would be curious as to what and when future expansion occurs. Thank you. Chair Holman: Thank you. Ben Lerner to be followed by Sally Probst. Mr. Ben Lerner, Palo Alto: I would like to thank the Planning Commission for letting me speak before them on this important matter facing Palo Alto. First to avoid any misunderstandings let me say without hesitation ! hold the Stanford Medical Center and its staff in very high regard. Every member of my family including myself we either born there, treated there for something, or both, and 1 am proud to have such a well known facility in my community. I just want to make a few general comments about some general sentiment, however. I have concerns over the magnitude of this proposed expansion and its impact on Palo Alto and surroundings. So I would like to urge the Planning Commission to carefully study the financial benefits and costs to Palo Alto from this proposal and to work with Stanford to develop suitable mitigations for any net costs that would be borne by the City. For the Medical Center to function it must fit harmoniously into the greater community in which it is located. There must be ample roads to carry workers to and from the expanded center, there must be adequate housing nearby at all price levels for the expanded workforce, and any new housing must be supported by schools, parks, shopping, etc. I want to urge you to ensure that all this is provided for as part of the planning process and in a way that doesn’t place any unfair tax burdens on Palo Alto taxpayers. Otherwise we may start hearing of ambulances that can’t deliver their patients to the emergency room because they are stuck in traffic, or the overcrowded schools that discourage top tier researchers from moving here. That would be counterproductive. To ensure the best possible outcome for Stanford, Palo Alto, and surrounding communities let me suggest a few particulars. Let the EIR be completed prior to addressing the impact of this project, as that will provide the hard data needed to make decisions. Consider the cost to taxpayers in deciding what should be mitigated, regulated, or planned. Use updated traffic models when assessing the impacts of the additional traffic generated by the projects. Consider that Stanford is a regional facility providing benefits far beyond the city limits of Palo Alto. For example half or more of Stanford’s patients are from San Mateo County thus the impacts of this expansion should not be borne by Palo Alto alone. Lastly, this is a billion dollar project. If the cost of impact mitigation is in the tens of millions that is an additional cost to Stanford of only a few percent but it could easily amount to one-third or more ofPalo Alto’s annual budget of $140 million, which would overwhelm a city of our size and place an unfair burden on its taxpayers. So please work with Stanford and surrounding communities to come up with an expansion plan that works for everyone involved. Thank you. Page 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Thank you. Sally Probst to be followed by Bob Moss. Ms. Sally Probst, Palo Alto: Greetings to the Commission. I was very impressed with the preliminary report of the expert that the City had hired. I think that was an excellent move to hire an expert to report to you directly. I found I learned a lot of things, as did some of my neighbors and friends. For example, we were not aware that some states had already gone further than California and had required that new hospitals would have single family rooms. We were not aware that this was a standard for teaching hospitals and for the larger hospitals. It was interesting to find out in fact it was good to find out that Stanford was in the mainstream on that. ! think it would be helpful for some more information to the public generally like that kind of information. There have been a lot of studies about hospital errors that derive from multiple patients in one room. I am personally aware of one hospital error that happened to my father who was in a room with another patient and the test results were confused. It would be important for the City to be informed about these kinds of things. I have not read the complete preliminary report of the expert so maybe this next point has already been covered. I think it would be helpful to have some understanding of how Stanford and Packard hospitals are projecting the use of their spaces if there is multiple use of spaces in times of trauma or some natural disaster. !t would be desirable to know if there is already planning in the works for how spaces could be used not only for their original purpose but also for handling large numbers of victims, let’s say, of a natural disaster. I think ! would like to just mention that when we are talking about no new net trips, and no new net students, no new net cars that maybe we should talk about no new net patients. Thank you. Chair Holman: Thank you. Bob Moss to be followed by Karen White. Mr. Robert Moss, Palo Alto: Thank you Chairman Holman and Commissioners. The first point I would like to make is I am dubious about the justification for the additional rooms and basing it on turn aways because there are a number of reasons why patients could be turned away from Stanford that have nothing to do with room capacity. One of them would be for example if they have insurance that isn’t covered at Stanford and so they are taken to a hospital like Kaiser where they are covered. Another would be that they don’t need Stanford they need something that is available someplace else so it is easier to take them to another hospital. So I am not convinced that the room is justified. ! am, as you know, quite concerned about the size and the bulk that is proposed and 1 think Commissioner Lippert had some excellent ideas. If you put some of the facilities underground and there are a lot of things you can put underground. I think radiation obviously, surgery, some of the support facilities, libraries, and cafeterias those could all go underground. I don’t see why the building can’t be made larger in area and shorter. It Page 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 is not like Stanford has no land there is lots of land available at Stanford and the hospital could use some of that. So I think the bulk should be reduced. In terms of mitigations one of the things that should be done, this project is going to take at least ten years it could take 20 years. During the project mitigation should be imposed reducing traffic, reducing impacts from the development, providing housing, and we should have buildings for each of these. Part of the development is done and then you look at whether the mitigations have been implemented and if they work adequately. If they don’t then the next phase can’t start until the mitigations have proven successful. Only after the mitigations or new mitigations have shown that they work would the next phase be allowed. That is not new that has been done in a number of projects before. So that is something that definitely can be imposed and should be. One of the other things that concerns me hasn’t been talked about much is the scale and the size of Lucile Packard Children’s Hospital. I understand the reason that it is the dimensions that it is and the size that it is is not because that is what is needed but because there was a proposal to actually rebuild the hospital in another city, in another location, and the plans were drawn for that location and then it died. So existing plans were taken and plopped back in the current location, not because it was necessary but because it was convenient. So again, ! think the size and the height of that building should be reduced. It should be compliant with the Comprehensive Plan and the height limits. What I don’t think is appropriate is to justify large, tall, bulky buildings and say you have to do this functionally. There are other ways the building can be done and other ways the functions can be operated. By the way, I am also concerned about having elevators up to the sixth and seventh floor if we have power outages. You are going to have a tot of people trapped on upper floors and you are going to have a terrible time getting them out. They should be closer to the ground not higher up. I think all of these mitigations should be looked at carefully. Thank you. Chair Holman: Thank you. Karen White to be followed by Mark Sabin to be followed by our final speaker, Penny Ellson, unless there is someone else who would like to turn a card in. Ms. Karen White, Palo Alto: Thank you for this opportunity. My comments have been made by others so I will just highlight a few things that I think are especially important. The first thing is I would urge that a Development Agreement not be finalized until after the environmental review is complete. It makes no sense to do things backwards. I have specific concerns, as you may know, about housing generally. Specifically regarding this project there has been a question raised as to whether there is a nexus between the proposed expansion and housing need. I would note that what differentiates Stanford from other developers is that Stanford can and does require that its housing units be occupied by Stanford employees. So within this context I believe that there is an appropriate nexus particularly for affordable housing that would be required by this expansion. I am told one acute need is for housing for nurses. This could be built by Page 29 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Stanford as a 100 percent affordable project that would not result in the kind of overbuilding that we see from inclusionary zoning requirements. Finally, that both the medical and shopping center expansion would bring regional benefits at the same time we should insist that the impacts and/or costs also be borne regionally not by Palo Altoans only. Thank you. Chair Holman: Thank you. Mark Sabin to be followed by Penny Ellson. Mr. Mark Sabin, Sunnyvale: Good evening. Just a few points I would like to make tonight. First of all what was said tonight does seem reasonable on the face and I think with the cooperation between the City and Stanford I think those numbers will be proven out to be legitimate. If you are indeed going to take a look though at some of the lower level and spreading the building out I think it would be legitimate to do an EIR on those and determine by doing such what impact it is going to have on security and also prevention of spreading of disease and all those issues. Quite frankly ! think the higher building is going to make security issues less, it is going to make disease spreading less, and I think that is going to be much more of a critical issue as we move forward. The Mercer germ alone is getting more and more serious. Another issue. Over the last ten years people with incomes of less than $65,000 have been moved out towards the perimeter of the Bay Area. Now about a year ago I did an analysis of salary ranges for healthcare in this area. About 30 percent of the folks who work in the healthcare industry make less than $65,000 a year and about 85 percent of the folks in healthcare make salaries less than $130,000 a year. So when you combine the migration patterns as they exist now on top of what the price ofoil is going for and what it is probably going to go for in the next few years, and what impact the housing prices are in this area, I think it really is important to be mindful of the context of a hospital. People have to work there all the time. Hospitals don’t close down for holidays or even emergencies. In fact they are even needed more in emergencies than they are in regular times. If the migrations patterns for affordable housing is beyond levees, beyond fault lines I think we create serious problems for staffing for a very serious facility for this community’s well being. So I think Stanford has done a better job than most entities in this are as far as providing housing for its people. ! think that the City and Stanford have worked in good faith to address this issue. I think it is an issue that does need to be addressed and the environment impact of not providing housing for critical contributors to this development are important. I think I fully support looking at that and making sure that those issues are addressed. If they are not addressed adequately those are the ones - it is going to have a negative impact on the senior population in this community and the rental population community because those are the ones if we don’t do anything that the rental prices are going to be probably jacked up the most. Finally, in terms of whether it should stay static in terms of the bed rate that is probably applicable if you don’t factor in the fact that the population of the Bay Area is going to increase by about 2.0 million by 2035. So this hospital is taking that into consideration. Page 30 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 So of course you are going to need more beds just to service the increase in population. Thank you. Chair Holman: Thank you. Our final speaker is Penny Ellson. Mr. Penn~’ Ellson, Palo Alto: I am speaking as an individual tonight. ! just had a couple of questions. I am about to reveal that I am a National Public Radio junkie and today on NPR 1 learned that some regulation change was announced today that changes the requirements for seismic retrofit for hospitals. I am wondering if Stanford is going to be reevaluated by these new regulations. They said a hospital could be re-regulated and then moved to a lower risk category but might move a deadline which could help us out in our process. So I would sort of like to hear Stanford respond to that tonight. I want to echo what I heard from Karen White. I wanted to talk tonight about regional support for mitigating impacts of this regional facility. This is not going to be a hospital that serves Palo Alto this is going to be a hospital for everybody in communities whose hospitals have been shutting down as we heard tonight. I have been following developments over the last couple of years and one of the concerns that I have is we approved big projects and then six months later the VTA pulls the bus service that served that project and we have to fight to get it back. 1 am wondering what kind of commitments we can get in writing from the other communities in this region who want the services this regional facility will offer. I hope that Stanford will take a very active role and collaborate with the City making sure those regional supportive mitigations come to us. I would just like to ask that in response to the comment on the Charleston/Arastradero plan, I wasn’t going to talk about this tonight, but the E1 Camino intersection is functionally a meter for the Charleston/Arastradero Corridor. So in fact it is possible that a large increase in traffic on El Camino could impact how well the plan works. So I hope that the Environmental Impact Report will take a look at that intersection. I think I have already asked Staff about it and they said that the data is probably readily available in information we have so it shouldn’t be a problem to do that. Also, I was looking at th~ timelines. I am very interested in understanding precisely how EIR development and the Development Agreement are happening simultaneously. There may be something that I don’t know about this process but ! guess I would like to have some explanation about how that works. How do you know what you are negotiating on if we don’t know what the impacts are going to be and what mitigations might work? It just sounds like an incredibly difficult task for Staff and I want to understand that better. Then finally, I want to just address quickly the mitigating secondary impacts. If housing is going to be a mitigation then a question that occurs to me is what will the impacts of that housing be on our school systems and the impacts that come from that mitigation. Will that be addressed in the Environmental Impact Report? That’s all, thank you. Page 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Thank you. Given that it is just a bit after nine we are going to take about a seven-minute break. If we could reconvene, please. Commissioners, we are back to questions for Marlene, our consultant. I believe Commissioner Sandas you have another question? Commissioner Sandas: I have a question based on Marlene’s Peer Review but it is actually for Staff. Is that okay? Chair Holman: Okay. Commissioner Sandas: One of the things that you are talking about in hospital configurations is he vertical versus the horizontal balance relative to the overall building site. Based on your review you say that the building at seven stories tall, 120 or 130 feet is correct. So there is something that concerns me about that. One of course it is a variance from our Zoning Ordinance on the one hand from the City and the zoning standpoint. On the other hand not being part of the medical field and not ever having been part of building a hospital before I have to rely on the judgments of the people who have. So being that this is in conflict with our zoning but it seems like it is a necessity for this particular hospital. How do we ensure that if this height is chosen and accepted and built, how do we ensure that this does not become a precedent for other buildings in the rest of the community? At Stanford, at the hospital, ! don’t know whose view that 130 foot building would be impeding. ! can’t quite picture whose view would be getting blocked. I just wonder how we could accept this and also maintain our Zoning Ordinance throughout the rest of the community. Mr. Williams: I will try to respond and if our attorneys have any suggestion we’ll let them add on. First of all ! would say that Marlene’s analysis ! think has indicated to you that this vertical configuration is a generally accepted approach today but there may be some flexibility in there. So first I don’t necessarily assume 130 feet it could be a story less or it could be spread out. Commissioner Sandas: Right, right but I am thinking it is going to be more than 50 feet. Mr. Williams: It is going to be way more than 50 feet I think we know. So I think that is one of the reasons why our thought is that if this is an acceptable project at some significant height above 50 feet that creating the zoning district for hospital is probably the best way to do it rather than a variance or some kind of exception that does lead somebody else to say well we want an exception or something like that. They would have to be saying we want a hospital zone for a new hospital and that 1 think is a much less likely opportunity to do that. So in terms of the interest of trying to protect the use of that elsewhere that is the best way to do it. Now that said, that does open a door. That is a height that none of our zoning districts currently allow. So by doing that somebody has at least something to point to and say well that district over there allows more than 50 feet so I think we ought to amend Page 32 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 something here to allow it. You can never say that it doesn’t create some thought of precedent or something but the district approach is preferable from trying to focus that on the particular use issues that revolve around this project as opposed to an office building that comes in in a commercial district or something. Chair Holman: I have a question for Staff. Will we have another opportunity to ask Marlene questions? The reason I am asking is because it is 9:20 and we have not yet gotten to the issues, mitigations, and public benefits portions of the item. So this Commission can hang in there pretty well but also there are limits to attention spans and such. I am hoping this isn’t our only access. Mr. Williams: No, I think what we would like to do is certainly she has heard some of your comments tonight. I would encourage that if you have others offline that you want to send to us that we can pass along to her so she can consider that. She is going to be refining the report and we can bring her back to you then in a couple of months or whenever that is, and as I mentioned before she is still getting tricklings of some additional data coming in as well. So she can come back and report to you again, update you on changes, and report back to you on the additional findings that she has. Chair Holman: So if l could propose and if Commissioners are amenable to this we go one more round, 1 have not yet asked a question, just ask a question, don’t wait for responses, just pose the questions, and then if we have other additional questions we can ask those online. Then those would come back to us. So if we might just finish up this second round. Commissioner Garber. Vice-Chair Garber: So we are not asking for answers we are just posing the questions? Chair Holman: Correct. Vice-Chair Garber: Okay. Ms. Berkoff: Excuse me if I may interrupt. So you don’t want me to respond, is that right? Chair Holman: If you have brief responses or if you need clarity of the question then that would be okay. I think mostly clarity of question might be helpful. Ms. Berkoff: Okay. Chair Holman: Okay? And if you have a suggestion on any better use of your time then we are open to that of course too. Ms. Berkoff: No.. If it is a simple, simple answer I will give it otherwise I will just make sure ! understand it correctly and take notes. Chair Holman: Okay, great. Thank you so much. Commissioner Garber. Page 33 ! 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Vice-Chair Garber: You presumably have spent more time with the data than perhaps with the exception of some people in the room than any of the rest of us. Has any of your analysis or investigation of the data resulted in recommendations that you would make to the City and/or suggestions for additional analysis or planning recommendations to Stanford for how the project should be pursued? Ms. Berkoff: 1 understand your question and I have a few and ! will pursue them and try and respond. Chair Holman: Commissioner Keller. Commissioner Keller: In terms of your analysis and review of the Stanford process and methodology you mentioned that some of the projections are based on confidential data. I understand that sometimes the process for people who are reviewers get access to confidential data under a nondisclosure agreement to which they can analyze that data and then disclose analysis of the data but not the raw data. I am wondering if that is the process you will follow because it is hard to evaluate the conclusions without evaluating the source data and being under a nondisclosure may be a way of handling that. One of the members of the public mentioned the issue of elevators and power outage. That is an important issue but perhaps not as important as the issue of elevators and earthquakes. In a power outage there are emergency power supplies but in earthquakes the elevators might not be usable, they might jam in the cage. So understanding the relationship between that and the height is I think something we need to explore particularly since we are in dangerous earthquake territory. San Carlos, Palo Alto Medical Foundation hospital was considered. I am wondering the relationship between that and the affect of that on the projections of Stanford Hospital. It seems to me that the Lucile Packard confusion between 257 rooms, which is a projected future doesn’t make any sense to me. We should have 216 beds as the base case since that is the current case otherwise you are doing projections on projections which kind of get loosey-goosey. So those are my comments. Thank you. Ms. Berkoff: I have actually two very quick responses. With regard to confidential data a number of my analyses already include confidential data that they have shared with me that is not available to the public and that I have used in reaching some of the conclusions about comparability of decisions that they have made regarding space. So there are a few other areas I can try to get additional data from them. The other point is in regard to the power outage. You are right about the earthquake situation being a concern. The power outage is not a concern because hospitals are all built with redundant systems and separate generators. Commissioner Keller: Thank you. Page 34 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4O 41 42 43 44 45 46 Chair Holman: Might you note more specifically in the report where you have had access, not tonight, but had access to that confidential data so that we have the assurance that you have the data itselt’?. Ms. Berkoff: A quick answer is I have both of the individual room-by-room space programs for each individual hospital. Chair Holman: Thank you. Commissioner Burt. Commissioner Burt: My first question that I will be looking for clarification on in the future is a follow up to Commissioner Garber’s initial question on the planning horizon. I didn’t understand that the horizon was stated as 2016 but the hospital won’t be completed until 2020 or so. That didn’t make sense to me and I will await a more detailed answer. Then this is probably a question for both the consultant and Staff. On this issue of confidential proprietary information it seems that information that would be calculating an actual needs demand would not be proprietary but information that is a business plan that is in order to have a competitive relationship with other hospitals in the area that that may very well be proprietary. So I would like to understand what Stanford is treating as proprietary information and what is publicly available to us. It seems that we are going to need to have as much shared as possible by Stanford if we are being asked to have some very significant accommodations by the community then we need to have open and forthright communication on the basis for claming those needs. Chair Holman: Commissioner Lippert. Commissioner Lippert: What is not confidential is that nonprofit hospitals by federal law are required to follow certain guidelines. That is for them to be able to have nonprofit tax status. If Stanford is going to be operating as a nonprofit entity what specific requirements by federal law are they required to meet? A couple of examples that I can give are I believe they have to have an emergency room. Ms. Berkoff: I am s.orry I wasn’t hearing you. Commissioner Lippert: I’m sorry. To give you an example I believe they are required to operate an emergency room for instance. They are required to accept Medicare and Medicaid patients. Those are just a couple of examples. Then one other clarifying question I have for you and maybe you can just give me a quick answer. The individual patient rooms they would also accommodate family members that wanted to sleepover, is that correct? Ms. Berkoff: That is correct. There are more generous accommodations for family members in the pediatric rooms than in the adult rooms but in both cases it is possible, yes. Page 35 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4o 41 42 43 44 45 Chair Holman: I have a couple akin to a couple of other questions that have been asked this evening. It has to do with satellite facilities, satellite so to speak. This doesn’t have to do so much with how much other hospitals are expanding and how that might affect the need to be filled by Stanford but rather as you are looking at the project proposed you are looking at it as an architect and as a Peer Review space planner but how might you be able to identify the impact positive or negative of taking some of the square footage, beds, and moving it to another location? In Redwood City there is some Stanford Hospital facility for instance. The Palo Alto Clinic for instance has a number of facilities around the area. Ms. Berkoff: May I clarify? Chair Holman: Yes. Ms. Berkoff: As a clarification on that are you talking about moving inpatient beds to another hospital location where there would be a whole satellite hospital or are you talking about contracting out beds for care? They already do the latter. Chair Holman: The former. Ms. Berkoff: A whole separate satellite hospital somewhere? Chair Holman: Yes, although it might be worthwhile to have both especially if they already do the latter but certainly the former. Ms. Berkoff: They do contract out beds to others, l am trying to think of some of them. I have it written down somewhere. Okay, so you are talking about inpatient care you are not talking about outpatient satellites. Chair Holman: Correct. Ms. Berkoff: Okay, I will find information on that. Chair Holman: The other is the local patients and the turn away rates. Part of that has to do with from my perspective even the Stanford employees who can utilize Stanford Hospital and Stanford Medical Center what do those numbers look like? We know that there is regional and even international draw for the hospital but if we are being presented with local impacts it would be good to know very locally what the use is by those Stanford employees. Ms. Berkoff: Do you mean you want to know the utilization by Stanford employees or do you mean you would like to know if any Stanford employee are among those who are not accepted, who are turned away for whatever reason, lack of a bed or whatever? Page 36 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Again, both would good and the latter would be especially helpful. Both, yes. Ms. Berkoff: If any. Okay. Chair Holman: Any other burning questions from the Commissioners? Commissioner Burr. Commissioner Burt: Do you mean just questions to the consultant or to Staff as well? Chair Holman: To the consultant at this moment. Commissioner Keller. Commissioner Keller: I am wondering if in the interest of time if we come up with other questions can we forward them to Staff to forward onto the consultant? Mr. Williams: Absolutely, and she does have your list of questions that you sent this morning. So if we didn’t get to some of those she will look at those as well. Chair Holman: Okay, thank you so much. Really appreciate your time and your expertise. Ms. Berkoff: Thank you. I will do my best to get answers for your many questions. Chair Holman: Thank you. We look forward to seeing you again. So Commissioners, are there questions for Staff before we go into our comments on the issues, mitigations, and benefits? One point of clarity here is that we will not this evening be differentiating between mitigations, mitigation measures, or public benefits. The reason is because we don’t have the Environmental Impact Report so we don’t know what the impacts are going to be so we wouldn’t know how to differentiate between mitigation and public benefits. So in our comments we should not differentiate. Commissioner Keller. Commissioner Keller: 1 am wondering if in order to structure our discussion we might want to have first the process discussion or the process discussion at the end and then separated out by the three major areas. So we go around on one area and then the next area as a way of structuring our discussion. Chair Holman: Commissioner Garber. Vice-Chair Garber: Yes, there was an email to the Commissioners regarding a letter to the City of Palo Alto from the City of Menlo Park. It came out late in the afternoon, 1 had meetings, so I am wondering if there are topics in there that the Commission should be aware of or issues that we should be made aware of that pertain to our conversation this evening. Chair Holman: Commissioner Lippert would like to add on to that question. Page 37 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Commissioner Lippert: I also had received it late in the day and I sent an email to Steven Turner asking if there would be representation from Menlo Park to speak to us as well as Santa Clara County Planning Commission. Mr. Turner: The letter that was emailed to you late this afternoon was Menlo Park’s response to the Notice of Preparation that was released in late August seeking comments for the review of the Environmental Impact Report. Menlo Park sent back the letter that was emailed to you regarding their areas of concern that they would like to see addressed in the report. It focused on transportation issues, aesthetics, noise, hydrology, hazardous materials, water, construction impacts and growth inducing impacts. None of these are particularly significant that you would need tonight for your review. Certainly we will be reviewing these comments as part of the Environmental Impact Report process but there is nothing specifically that the Commission needs to be aware of tonight. Menlo Park is asking for a much wider analysis of intersections within their city than we were originally intending to do. We have reached out to the Menlo Park Transportation Staff to better understand their reasons why they would like us to look at these intersections. We are cooperating actually very well with their staff and sharing data so that we can plug that data into the model. So we can get some pretty good results without a lot of extra work. So we have reached out to Menlo Park and certainly answer their questions. We are also available to their staff and their Commission and their Council to provide them with updates regarding the projects and answer their questions. We have not typically sent out copies of the Staff Report to their Commissions or Council or to their staff but there is always an open invitation for the Menlo Park staff and Commissioners to attend these meetings. They are part of our notice list so they are aware of our schedule and can attend. Chair Holman: Any other questions for Staff at this point about the Staff Report? Again, just general questions of clarity not for the specifics. Seeing none we can to them to addressing the issues of Benefits and Mitigations. Let’s undertake the Land Use and Open Space first as it is organized in the Attachment A. Commissioner Burt, would you care to start? Commissioner Burt: I will pass because I want to organize my questions now according to the sequence that you want them. Chair Holman: Commissioner Keller. Commissioner Keller: Thank you. The first thing is something that was mentioned based on a question I asked Staff earlier. I believe that the nonresidential development cap should be a specific item under the Land Use issue. I think that is a reasonable thing. The second thing is a question under item number 1 O, height versus open space. I think that we have identified open space as one of the uses for which the height versus something tradeoffmight be. So currently hospitals have a certain amount of FAR and a certain amount of height. If we ignore height for the moment and just take into account Page 38 1 2 3 4 5 6 7 8 .9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 the FAR allowed for hospitals by Stanford saying that they prefer having a tall building so that it is dense and uses up less space that means that frees up land area that could be used otherwise. So the question of whether that space is given some other use that is a public use, whether it is open space or some other use other than open space such as schools or whatever, should be considered. With respect to the letter I, Palo Alto Intermodal Transit Center, number 19, Housing Site, I actually think that is a fundamentally bad place for housing. It is only 30 housing units and ! can think of a whole host of better uses for that space than putting housing there. Chair Holman: Just for clarity, when we had pre-Commission meeting we decided actually that ! and 19 should be deleted because they were not particularly logically placed here. So if that helps at all. Commissioner Keller: I totally endorse that idea and I will talk more about what vision for the transit center when we get to Transportation and Linkages. Thank you. Mr. Williams: If ! could just clarify that what we were talking about though was that 18 would also include, when we talk about county and city locations, would also include intermodal transit center. What we are talking about at this point is that that’s in the discussion as far as potential housing sites. We are not necessarily trying to decide whether one or the other is good or not but that it is in the mix. Chair Holman: Correct. Vice-Chair Garber. Vice-Chair Garber: On item number 11, under E, Urban Design, Hotel Location and Size ! believe we should have an X in the SUMC column as wel!. That was discussed at one of the Commission meetings by Commissioner Keller as a possibility there. Chair Holman: Commissioner Sandas. Commissioner Sandas: My question is under letter H, Housing Needs, number 15 where it says provision of market rate versus affordable units. There is an X in both columns which is terrific but I am wondering what tools if any do we have available to ensure an adequate number of affordable units? Do we have estimates available of the types of jobs that this project will generate and the housing that is affordable that will be required? Just hearing from Marlene tonight or one of the speakers tonight it was said that some hospital jobs are lower paying than others. I just wanted to know what the ratio of those jobs to the higher paying jobs would be so we can ensure an adequate amount of affordable housing. Chair Holman: Commissioner Lippert. Page 39 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Commissioner Lippert: Under item C, number 6, there is an indication of transferable development rights for Foothill preservation but then when I go further down to E, 12, Historic Preservation it doesn’t cite transferable development rights for historic preservation which I know is something we have in our Zoning Ordinance. Chair Holman: Commissioner Burt. Commissioner Burt: First I have a question on the size of what is called Area B for the potential housing sites. It is also listed on the map as ’5.’ ! am not quite sure why we have a mixture of numbers and lettering. The acreage is not listed and the residential density is to be determined. It is a large acreage. Then on page three of Staff Report under GUP Site B if that is the same area it lists 125 units which either means that only a fraction of that area is envisioned to have housing or it is an extremely low density because it is a great deal of acreage. Then we have the impact on schools, it is B, 3. It says School System Capacity and l think that should be expanded to capacity and other impacts. Then under G, 14, Surge Capacity, ! would like us to make sure that we are identifying how we would have mechanisms to assure that what we have been told is one of the justifications for the increase in beds is to accommodate emergency surge but if they just over time occupy them back up to 90 percent then we haven’t really accomplished that. So I presume there would need to be some mechanism that would assure that there actually would continue to be emergency surge capacity in the long-term. Then there is also the question on the local physicians or accommodations or ability to obtain alternative space to Welch Road. What I heard the consultant say was that Stanford had said that those accommodations were being made. I didn’t know whether there has been any effort to survey those physicians and find out whether their perception is the same. Then finally, I presume that the fact that we just got Menlo Park’s concerns today for a September 27 letter was just an omission and that we in the future would be getting any of those comments with our regular packet. Mr. Turner: That letter specifically was for the NOP, in response to the NOP. So it was addressed to Staff for the NOP comments. There will be contained within a scoping report that would be prepared and distributed but these letters were in response to the Notice of Preparation that was sent out essentially by Planning Staff seeking comments to be addressed back. Commissioner Burt: Well then I would still say that I would like to make a specific request that any comments by a neighboring jurisdiction are forwarded to the Planning Commission in a timely manner. Page 40 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Commissioner Lippert, you had a procedural question? Commissioner Lippert: Yes, a procedural question for Staff. We really don’t have any jurisdiction over school district requirements except in terms of what we have outlined here in terms of capacity. As it turns out the school district doesn’t completely align with the municipal boundaries of the City of Palo Alto it overlaps onto Stanford unincorporated county lands. What is our relationship to that? Ms. Cara Silver, Assistant Ci_ty Attorney: ! will attempt to answer that. In terms of the boundaries the school district is obviously a separate legal entity than the City and there is little mitigation measure that you can impose legally as a city to alleviate some of the school district impact. As part of the Development Agreement of course you can if Stanford is agreeable negotiate certain mitigation measures to address those impacts. Commissioner Lippert: So to clarify if there was more housing required and they had to build it in the unincorporated county lands that impacts the school district do we legally have anything to say about that? Ms. Silver: Again, as part of the Development Agreement that would be your ability and your entrde into that area. Chair Holman: Commissioner Keller. Commissioner Keller: To follow up on that, in the 2000 General Use Permit from the Santa Clara County when Stanford was required to build at least 2,400 housing units based on the build out that they are talking about and up to 3,000 housing units I believe there was a mitigation in which they offered land or money and the mitigation of those housing units was in fact the money that went to reopen and refurbish Terman Middle School. So in some sense the county has set a precedent for the General Use Permit as a kind of Development Agreement if you will in which a school mitigation was made for housing. So it seems that the City should be able to do the same kind of thing for mitigations that affect the school district as part of the Development Agreement. I just want to put that on the record and have that be considered as part of the excess land if you will that is not used because of the compaction of the hospital might be used for schools. Chair Holman: Vice-Chair Garber. Vice-Chair Garber: ! would simply like to add my voice and emphasis to item B, 3 regarding schools. I suspect there needs to be an additional item underneath H that provides the link to housing and regional impacts and potentially another link that deals directly with ABAG and how this affects that, can affect that, could not affect that. I think there is a bullet point under there that is specific to that. Page 41 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 4O 41 42 43 44 45 46 Chair Holman: ! will step in with a turn here for a moment. Under 1, Parks, I would add open space and permeability. Item 2, I would add Public Safety Building. Item 3, akin to Commissioner Burt’s comments I would be even more specific and say available lands for schools and playing fields. For 5, 6, and 7 I would add Stanford Shopping Center. Commissioner Lippert. Commissioner Lippert: I think under the first two items plus the ones Chair Holman has added perhaps also adequate onsite daycare facilities. Chair Holman: Commissioner Burt. Commissioner Keller. Commissioner Keller: ! would just like to reiterate the comments that were made by a member of the public regarding affordable housing and the issue that I understand that there is a nursing shortage in California. A lot of nurses are in the process of retiring. Therefore focus of the affordable housing provided by Stanford for nurses would be a good thing for the ability to attract and retain qualified nurses for the Stanford Medical Center and the Children’s Hospital. Chair Holman: Vice-Chair Garber. Commissioner Sandas? Commissioner Lippert? Commissioner Sandas: Are we still on the first topic? Chair Holman: We are still on Land Use, which includes housing. Commissioner Lippert? Okay, I have a couple more to add. Under F, 13, Services adjacent/within Stanford West and Oak Creek Apartments I would add to that services adjacent and within the specific projects, the Medical Center and the Shopping Center. The reason for that addition is because not all services, even though it is a large retail center, not all services and goods are available at the upper end shopping center that that is. I think those are the only ones that I have except I do have to a question of clarification about the process having to do with E, 12. That is the EIR is going to evaluate Hoover Pavilion and the hospital and I am wondering at what time will it be determined that the HRB will get weigh in on the adequacy of the EIR in that historic evaluation. Mr. Williams: I am not sure. I will have to go back and ask and see. They certainly would see the Draft and comment on it. ! don’t know whether it is a typical process to take the historic component of the EIR and specifically run that by. I don’t think we would have a problem with doing that, running that by HRB. Before the Draft is produced I am sure we will get some kind of historic report from them. Chair Holman: That would be good. I know with the Stanford Mayfield project for instance they reviewed the signage because of the historic aspect of that site where the soccer fields went but they weren’t included in the evaluation of the housing. So I just want to see that if there is or isn’t an impact they get to weigh in on whether there is or isn’t. Page 42 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Mr. Williams: Okay. Let me look at how we can incorporate them into that process at an earlier stage. Chair Holman: Thank you. Commissioner Burt. Commissioner Burt: I realize I have a broader question that wasn’t in one of the specific line items. Given that we now understand that the Peer Review does not necessarily evaluate the business plan and the need for growth projections of beds as opposed to the seismic and the modernization requirements that I think are much more clear. Who will do that evaluation on behalf of the City? I think it had been indicated to us previously that that was something that we would expect would come out of the Peer Review and now we understand it is more of an architectural review and not hitting that area. So is there some way that will be evaluated? Mr. Williams: You mean specifically the number of beds? Commissioner Burt: Yes, the growth in patients served and what the need basis is for that. Mr. Williams: I think she can come as close as anyone can. I think the question again is how much .... I see what you are saying like the sort of study that was done... We will have to go back and regroup and see because again that is an expensive proposition to get somebody to come in and do that. I don’t know how much it is but we can see. Commissioner Burt: We didn’t hear anything about or get to see and maybe Staffhas it, the PAMF study for the hospital in San Carlos and what light that shed on the local demand. We have Sequoia Hospital being rebuilt. Kaiser in Redwood City being rebuilt. Mr. Williams: Right and there was a study for both counties that was done and I think we need to look at that and get copies of that to you guys. Commissioner Burt: E1 Camino Hospital being rebuilt. We heard that all these hospitals were being closed but we are aware that seismic upgrades and then we are unclear on what that would result in in an increase in beds. Certainly the PAMF Hospital in San Carlos is a net increase and we don’t know what else is going on there and then how that relates to the total demand. Mr. Williams: It is something that may be able to get incorporated into Marlene’s expanded analysis and if not then we will see if there is some need to bring someone else. Commissioner Burt: Okay. Chair Holman: I have one more to add which has to do with Urban Design, E. I would like to add to that list transportation systems and linkages because there could be overpasses, underpasses, pedestrian, bicycle and the design of those facilities could also greatly impact positively or negatively the urban design of the project. Page 43 1 2 3 4 5 6 7 8 9 l0 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4o 41 42 43 44 45 So it looks like we are ready to move to Transportation and Linkages. Commissioner Lippert, would you care to start? Okay, Commissioner Sandas just said she is ready so we will go there. Commissioner Sandas: The first paragraph on Transportation and Linkages’ description the Area Plan Objectives, Transportation. It calls for expanded Transportation Demand Management program to be identified in order to reduce automobile trips because measures should be evaluated to feasibly approach a desired goal of producing no net new automobile trips. I have one comment and several questions about that. My one comment is that in order to feasibly approach a desired goal of producing no net new automobile trips ! think we have to reduce the number of automobile trips that are currently happening right now in order to get anywhere near a zero base. That is my comment. The question I have is where exactly are the net trips calculated? Are they calculated once the car tire crosses from Stanford Avenue or E1 Camino or Sand Hill onto Stanford property or are they calculated within the boundaries of the City of Palo Alto? As 1 mentioned the last time we were talking about this topic you know that in College Terrace there is a parking issue with Stanford employees parking in the neighborhood. That can only grow unless something real and measurable is put into place to keep that trend from spreading from College Terrace into other nearby neighborhoods. So I would like to see that not only is the traffic measured entering Stanford but entering key gateway points into the City of Palo Alto. ! will speak more to that later on this evening. The other thing, on item number 23, Expanding Shuttle System, add Stanford Shopping Center to that. Why not? Why wasn’t that there to begin with is my question. Chair Holman: Commissioner Lippert. Commissioner Lippert: I actually was going to say the same thing as Commissioner Sandas. I think that under number 23, Expanding Shuttle Service to Stanford Shopping Center. There used to be a time when I think that there were whole coaches of buses that used to bring people to Stanford Shopping Center. At least I think what we might be able to do is bring people from the transit center to the shopping center. Chair Holman: Commissioner Garber. Vice-Chair Garber: In the description that follows the word ’linkages’ above item J, which reads, "The project shall include designedand built features that promote linkages for pedestrians, bicyclists, and transit users from and within the SUMC to the Stanford Shopping Center, the Stanford University Campus, the Palo Alto Transit Center, Downtown, and nearby residential neighborhoods." I think I would rather see that as a separate item between I and J with the various places listed as numbers or subunits Page 44 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 underneath there. That is to emphasize that those are the connections, the linkages that we are looking to find ways to support. Mr. Williams: I am unclear on how that differs from number 21. Vice-Chair Garber: I guess what I am trying to do is find a way to emphasize the specific things we are trying to find ways for this project to support. I am thinking that one of the ways to do that is to separate those out and call it not traffic but call it linkages or connections or something of that sort. Does that make sense? Mr. Williams: So separately to the Medical Center, separately to the shopping center, or separately by modes? Vice-Chair Garber: Separately such that each line would be a different place that we want to link to these projects. They would be all wrapped up under a title that would either be called linkages or connections or improved linkages or improved connections. Something of that sort. Chair Holman: Commissioner Sandas has a follow up to that. Commissioner Sandas: Just a follow up query and comment. In the linkages that Commissioner Garber was talking about the last place is nearby residential neighborhoods. ! think that the spirit of the notion of the nearby residential neighborhoods was so that people who live in nearby residential neighborhoods could take a shuttle or easily be linked to the project sites. However, it is a double-edge sword and ! know ! am beating a dead horse but it is also an attractive idea to maybe drive from another community and park your car in a residential neighborhood because it is easily linked to one of the project sites, l just want to put in the record that we need to be careful in how we make our approach. Chair Holman: Commissioner Keller and then Commissioner Burt. Commissioner Keller: I think that first of all the County GUP has a requirement for no new net trips and as far as I understand the City of Palo Alto does not yet have that as a standard but it could be imposed as part of the Development Agreement. I certainly would be one that endorses the idea of no new net trips with a couple of provisos. First of all, that we want to make sure that we don’t have displacement of these trips which is I believe what Commissioner Sandas was referring to. The trips are displaced in that they don’t quite cross the border into the region and they somehow get close but the shuttle allows them to get the rest of the way. That gets to the next point, which is that under Linkages I am wondering why it says ’nearby residential neighborhoods.’ It seems to me that should actually be linkages throughout the city, throughout major portions of the city. I suspect that first of all there are 2,000 residents of the City of Palo Alto who work on the Stanford Campus. ! don’t know how many people who live in the City of Palo Alto who work at the Medical Center or the Shopping Center because that data is not yet available to us but I hope it will be available to us soon. Furthermore, there are lots of Page 45 1 2 3 4 5 6 7 8 9 10 I1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 patients and visitors who come to the Medical Center and the Shopping Center from various neighborhoods throughout the City of Palo Alto and not just from the nearby ones. So the idea of expanding shuttle service to the Stanford Medical Center and to the Shopping Center that allows for people throughout the city or major parts of the city to come and visit the Shopping Center and the Medical Center without driving would seem to be a good thing and should seriously be considered. Mr. Williams: Can I just add, there have been several comments about this and I know you went beyond just this, but this Transportation and Linkages language here I want to clarify if from the Area Plan. It was provided for sort of a context for the list below that. So we are not going to modify that language as part of this. What we will do is try to take that and fit it in and suggest where that would fit as far as a list goes for each of those. Commissioner Keller: Thank you, Curtis. I think that what might make sense is to basically delineate more line items under J and under K that give a finer granularity to this and that might be what Vice-Chair is referring to. I understand that the City of Palo Alto at some point in time had a transportation model and that there was some traffic model that was available. ! am not sure the extent to which that transportation model is current or has been updated but it seems to me that this is such a large increase that a comprehensive transportation model bringing that up-to- date and having a citywide model as opposed to sort of intersection-based models would seem to be a useful thing. I would certainly encourage that. I think that with respect to number 27, Transit Center Implementation, I read in the paper today that the California High Speed Rail Authority staff has endorsed high-speed rail going through the Pacheco Pass and going up the Caltrain line presumably. That is in the time horizon because they are thinking about service beginning as early as 2018 and that is in the time horizon for building the Medical Center. So we need to think about that idea of how that works in conjunction with the Medical Center and Shopping Center expansions and understanding the transit center implementation and also understanding how that might be more effective in terms of helping Stanford’s TDM programs, which are actually quite good, and expanding those TDM programs to a larger population. The faculty and staff TDM program on the main campus is really fantastic. The Medical Center is not quite as good but it is still pretty good and expanding those to broader populations is worthwhile considering. Chair Holman: Commissioner Burt. Commissioner Burt: I suggest that item 27, Transit Center Implementation, also include the Shopping Center. Then that we also look at as a mitigation the, I forget what we call them ! mean the smart signals like we have on Charleston. Then the other thing is that we have as a required mitigation we evaluate the commitment from other transit agencies given that this is a regional benefit that they are going to make the commitment to support transit to this location. Also that we have the cooperation so that we get a unified Page 46 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4o 41 42 43 44 45 46 transit program as well. Then also that we evaluate the relocation of the traffic signal in front of PAMF to Encina which may have a significant impact on congestion on E1 Camino as it relates to the Town & Country entrance there and for that matter as well as cars entering from Palm onto E1 Camino. Then this will hit again under sustainability but that we presume that AB 32 is going to have to be integrated within our future city requirements. Even though it has not been fully integrated yet the timeframe for this development is such that I think it very likely that citywide we will be adopting measures to respond to AB 32 and that that be an expectation of this entire project. All this other talk that we have been having about Palo Alto having no net trips I think will be trumped by AB 32 and the entire state is going to be moving in a direction that is very different from what we have done historically. So 1 think the focus can simply be on AB 32 implementation and it eliminates a lot of these other debates. Then finally if we do have a trip count method I think that it should be unannounced. As I think that we should for the core campus try to encourage the county to modify that to be unannounced because there is a natural inclination for trips to be modified in those periods where it is going to be most impactful. I know from friends who work on Stanford Campus that that is just an unwritten rule. Chair Holman: Commissioner Lippert. Commissioner Lippert: Item 29 and 30, in between the two of those I think there should be a little footnote or sub 29-a, which is that emergency vehicles stick to arterial routes as opposed to neighborhood streets. Maybe that can be worked out with the companies that San Mateo County subs out the ambulance service to. Chair Holman: Okay. For me number 20 should add Caltrain and school district. Number 21, mentions shopping center, transit center, Downtown Palo Alto, please add Town & Country Village. Number 23, Expand Shuttle System, I would think that should also include Stanford Shopping Center. I would like "Expand Shuttle System" be a little bit more specific, from where to where, schools, daytime, peak hour. I would like to see different approaches taken there. Number 26 and already number 27 add Stanford Shopping Center, so should number 26 add Stanford Shopping Center. For 26 also I for one have no reference point for that that is determined. So if there could be a reference point provided for that whether this is part of Development Agreement or mitigation or whatever there needs to be a reference point. Mr. Williams: Do you mean reference point as far as what the current situation is? Chair Holman: Yes. Most of the traffic issues and mitigations or benefits that mentioned here are local meaning Palo Alto. VTA and Caltrain have been mentioned but a member of the public did bring up a very good point, which is what are the assurances of those circulation and traffic mitigations. Not that we can have promises but what kind of assurances can we get? Another thing that I would like to see added is as a part of this Page 47 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 program is that there be as a part of the assurance there be an auditing system such that every year, two years, that there is a trip audit that would include not only number of trips but trip source, and trip route. So that if there need to be changes over the life of the project that those can be addressed. So in other words, ongoing mitigations. I think those are my only additions to Transportation. Commissioner Burt. Commissioner Burt: I am sorry I neglected to add one more specific item. Under additional public transportation to evaluate expansion of the shuttle system between East Palo Alto and the hospital on a direct route and possibly as a cost effective mitigation that is indirect impact to extended directly into the core campus. Chair Holman: Vice-Chair Garber. Vice-Chair Garber: It seems to me that one thing this section may be missing is an item that refers to the regional or extra Palo Alto impacts and potential improvements be they Menlo Park or others. Chair Holman: Commissioner Keller. Commissioner Keller: I understand this project will take place over an extended period of time and that there will be probably lots of large construction vehicles traversing from the Stanford Shopping Center and the Stanford Medical Center probably to 101. ! would assume that they would go along E1 Camino and San Antonio Road. 1 am not sure where they would go but the issue is understanding that route and the mitigations that occur due to the wear and tear on pavement, and congestion, and things like that for the construction vehicles should be taken into account. I endorse Commissioner Burt’s comments with respect to greenhouse gases and AB 32. In particular that is one motivation for the easier to measure no new net trips. One way to do the no new net trips I am happy with the idea of transferable credits. So the issue is if you reduce trips somewhere else then that should credit to some extent. If greenhouse gas reduction is a motivation then that would be a justification for transferable. l also endorse what Commissioner Burt said with respect to the traffic counts being unannounced. I remember when I worked at Stanford many years ago I heard stories about the counts of determining how much library use, what percentage of student library use for academic purposes versus research library use was supposed to be done once a year. For some reason it always happened during the summer when students weren’t around very much. As a result of that it had a beneficial affect to the overhead rate from the point of view of some administrators but not from the point of view from the faculty and staff. Chair Holman: Okay Commissioners, it looks like we are ready to go to Sustainability. Who would care to start? Vice-Chair Garber. Page 48 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Vice-Chair Garber: I am not sure this is a comment that affects this list as much as it is a way of thinking about this. It is clear that most municipalities are using LEED Silver Certification as the target for new buildings, which are public in nature. It seems to me that it would be worthwhile understanding that there is a possible additional public benefit if it goes beyond Silver. The other thing that I would just simply note is that I believe that in terms of clarification if we are talking about LEED for hospitals and those criteria. Chair Holman: Commissioner Sandas, do you have a question? Commissioner Keller. Commissioner Keller: Firstly, we had a talk a couple of months ago from the US Green Building Council who I believe owns the trademark on LEED. They objected to the concept of equivalence of LEED Certification. You are either certified or you are not. You are not equivalent to LEED Certification. The certification process is an auditing process. So if you are going to say you are LEED Certified you are LEED Certified. If you are saying equivalent it is just a promise. That is the first thing. The second thing is with respect to greenhouse gas impacts, which is item 38. ! think that AB 32 implementation is something that we should look at but as a baseline no new net greenhouse gases is a simple measure that is towards AB 32 which is going to require a significant reduction by 2050 from the baseline of I think 1990 but ! am not sure. So the sort of Hypocrites saying first do no harm so if you are going to try to get down to an 80 percent reduction by 2050 first don’t add any greenhouse gases to begin with. The next thing is I endorse the concept of one of the community members who talked about water use. Considering the climate change and the effects on the water patterns and rainfall and snow patterns the idea that the Stanford Shopping Center and the Stanford Medical Center should have no net increase in water use would seem to make sense particularly since ! would suspect that in the next ten or 20 years the amount of water that would be available to the City of Palo Alto will be less than is available today. Chair Holman: Commissioner Burt. Commissioner Burt: First I would like to make sure that we pursue something that I mentioned at previous meeting of the anticipated decline in the cost of clean energy sources, photovoltaics in particular, and that we as the design of the project is developed and the prospective return on investment of those sources we look at the anticipated cost at the time that they would actually be constructed as opposed to their current cost and anticipated cost of conventional energy. Second, I would like to ask Staffto evaluate what is the more appropriate way for us to look at the totality of greenhouse gas emissions. I believe that AB 32 also has a milestone for 2020 that is a moderate reduction below 1990. I suspect but ! don’t know that that would in fact have a greater mandate than no net trips but whichever is the greater requirement is probably what we should be focusing on. Page 49 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Then on the water use I believe that at a previous presentation we were told that the anticipated water use would be in proportion to the increase in size of the project and that seems way off kilter. 1 can tell you from personal experience when I was putting in a new manufacturing plant ten years ago we reduced our water use 95 percent at the time of construction. I am not saying that is necessarily the opportunity for a hospital but when you build from scratch with current designs, current concepts there is no reason that we should have to be looking at a proportionate increase to scale especially given that we are not even having a proportionate increase in number of beds, it is square footage that is being added. So I don’t know what the answer is on what should be the permissible increase in water use but it should be minimized to the greatest extent possible. Chair Holman: Commissioner Lippert. Commissioner Lippert: My colleagues are all commenting rather than asking questions so I will add one more comment. Eighty percent ofa building’s lifecycle costs are in the maintenance and operation of buildings. So I guess maintenance and operation should be looked at stringently not just that the building is manufactured out of sustainable materials. Chair Holman: Commissioner Keller. Commissioner Keller: Under Fiscal there is an item R. Chair Holman: Let’s come to that after we finish Environmental Sustainability first. We will come to Utilities and Services and do Fiscal if you don’t mind. Commissioner Keller: Sorry. Chair Holman: ! have a couple of things under Sustainability. One of them is fill which was an issue that was brought up earlier. The wear on the roadways, which has already been brought up, was one of my things to add. Then I have another one to add which is where it is feasible to consider geothermal. One more, and this could even be under Land Use or it could be under Sustainability, it could be either place I think. Similar to the audit for trips under Transportation I think there should be a report every three years or something like that, ! am just picking a number, about employment rates. The reason for that is because once we build the boxes models and means of delivering service change. So we aren’t going to always know how many employees are there and what demands are being added to community services plus our roadways. So if there could be a report every three to five years something of that nature so we can do employee counts and evaluate those impacts that would be helpful. Curtis, did you have something to add? Mr. Williams: ! just was waiting for you to finish your list and then ! wanted to ask about fill. Page 50 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Okay. Then the other one I wanted to add about sustainability is this would be to the benefit of Stanford as well as the community. I brought this up in pre- Commission, when we approve the projects whatever gets approved is there is a mechanism that could be built in such that we are not approving something on X date that is then outmoded when the project is actually built. So if there are advancements, and surely there will be, in solar for instance then Stanford wouldn’t be held to some standard that isn’t to their best interest or the community’s best interest. Curtis. Mr. Williams: So with the fill is your main concern the issue of the trucks hauling the fill off or the ecological impact of the fill? Chair Holman: Primarily the latter but the former would be mostly covered under trip generation I think but both really. Mr. Williams: That is what I was going to suggest is that the former would seem to be more of a Transportation issue of getting back to some of the construction, truck traffic, and all that. Okay, so I guess I haven’t envisioned so much fill on this project as much as the cut. So it is the fill that is being hauled off the site and the cut that becomes fill and goes somewhere else. Chair Holman: Correct. Any other comments? Commissioner Keller. Commissioner Keller: To follow up on Chair Holman’s comment about fill or if you will negative fill, cuts, excavation, it would be useful to identify where that material is intended to be transported. Chair Holman: Okay Commissioners, it looks like we are ready to go to Utilities and City Services. Who would care to start? Commissioner Keller. Commissioner Keller: 1 already indicated my comments about water, which apply here as well. With respect to fiscal impacts I think it would be helpful to have an overall balance sheet where there would be expected costs from increased services that have to be rendered and where there would be potential revenue opportunities. It would be helpful to understand those costs. The costs may be indirect. For example costs from increased residences, costs from wear and tear on streets and things like that. So in some sense it would be helpful to have some sort of overall cost and revenue balance sheet. Chair Holman: Commissioner Lippert. Commissioner Lippert: A couple of things. Number one I believe that Palo Alto is one of the first EPA green power cities in California and in the country I think we are maybe number two. What it represents is that a minimum of five percent of our utilities are generated by renewable resources. So one of the concerns that I have is that the new facility might create a deficit in terms of putting us under that five percent mark in terms of us not becoming an un-EPA green power city. So maybe as a part of this it should be looked into where those additional energy demands are being generated from whether Page 51 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 they are being produced by a coal powered generator, electric generator, whether additional wind farms are being used. Then just a second thought is a kilowatt saved is a kilowatt generated. So that should be looked at as additional measures for conserving energy within buildings. Chair Holman: Vice-Chair Garber. Vice-Chair Garber: ! will simply emphasize my agreement with some of the potential mitigations and/or public benefits that could be derived from this which included some of the things that have already been suggested, rainwater, storm water collection and redistribution, gray water, the potential that was mentioned recently as well to have these properties participate in a public solar co-op for instance. 1 think there are a bunch of different ideas and the topics here probably cover most of them. That’s it for the moment. Chair Holman: Commissioner Burt. Commissioner Burt: l guess these comments are under Fiscal Impact. One is to try and find out whether there is a reasonable nexus between this project and a portion of the cost to the Public Safety Building. Second, the impacts fiscally on the schools and whether that can be integrated as part of the Development Agreement. If there is some mitigation for the housing impact, in particular affordable housing, that it not be limited in consideration to Palo Alto but look at adjacent communities where staff members who work at the hospital may be living. If we keep thinking of this as not only a service regionally but employees who are in our sub-region then we probably should look at that impact in a broader way as well. Then finally, just kind of a summation on fiscal impacts and cost impacts. I think it is important that we not look at dollar extractions as what we care about. It is mitigations and consequently things like what Commissioner Keller talked about of looking at trip avoidance in some other related area if we permit that and Stanford chooses to do that as opposed to us requiring it then ! think that is a reasonable thing for us to be able to consider. If there is a more cost-effective way that they can further reduce trips to the core of their campus say, as a way to mitigate the impacts of this project then so be it. If extending the Marguerite Shuttle into other places in the community avoids trips more cost-effectively then that is fine as well. So we recognize that resources are limited, resources for the City, resources for Stanford, so I would really encourage all parties to look for innovative, cost-effective approaches. Chair Holman: Commissioner Keller and then Commissioner Sandas. Commissioner Keller: 1 can imagine a cap and trade system for car trips. With respect to Utilities the notion of emergency power supply and in particular in the event of an earthquake where the power supply might be out for an extended period of time there is Page 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 both the pollution aspect of the emergency power supply as well as the reliability and the continual availability of fuel and how long that emergency standby power supply can sustain being in that capacity. Similarly, I remember we had this whole discussion awhile ago about emergency water supply. I still feel unsettled about the emergency water supply. ! am glad that the community voted for that but I am concerned that in the event of an earthquake, which is why we have the emergency water supply in the first place, the supply pipes will crack and therefore leak all our water. So it seems to me that the notion of insuring that the supply of water to Stanford from the emergency water supply to the hospital which seems to be the most critical use of water in an emergency besides fire make sure that that is done in a manner that the supply is reliable and the pipes don’t crack and some ways of avoiding the water supply leaking out into the rest of the city where there are cracked supply pipes. So I think that is something of concern. Chair Holman: Commissioner Sandas. Commissioner Sandas: Just one thing to sort of piggyback on what Commissioner Burt had mentioned and actually I had mentioned earlier when we were talking about no net new trips. I said I thought that we needed to start reducing the trips now so that when this project comes we can say we have no net new trips. There are going to have to be tradeoffs. When the Stanford Shopping Center grows I can’t imagine that people are going to be coming on the bus and on the train and so forth to do their shopping. People usually come by car so they can carry all their packages home. Having saidthat, and having had this discussion about no net new trips I would like an explanation of Q, 47, the Transportation Impact Fee. We have it checked offunder both the hospital and the shopping center. What exactly are we intending? Mr. Williams: Well the City has fairly recently adopted a Transportation Impact Fee that covers the entire city and it is based on the net increase in number of trips. So I think we have it down here as is that an approach the City wants to use in terms of assessing that fee on these projects versus some of these other, which gets back to the issue Commissioner Burt just brought up as far as maybe we would rather instead of imposing that fee have specific measures taken that result in less trips. So I think that is on there as far as one of the options as far as fees. Do we impose that on either or both projects or do we look at other solutions? Commissioner Sandas: I guess my question is how much do we really believe in the notion of no net new trips? To me the fact that it is there indicates that whoever said it should be there doesn’t really believe that there is a possibility for no net new trips. Mr. Williams: I think it is a broader thing than that. It is possible that you could be using these fees for some other purpose. If these fees go into help advance the shuttle system somewhere else then maybe that is useful in reducing trips and you get an overall net benefit of that. Page 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Commissioner Sandas: So an option then might be rather than assessing the fees in the actual dollars as Commissioner Burt had suggested the Marguerite would expand to more places in town. So it would be a tradeoffmore than a dollars and cents thing. I am getting it. Mr. Williams: Right. Chair Holman: Commissioner Lippert and then Vice-Chair Garber. Commissioner Lippert: I have a couple of small questions or clarifications. Under Q, 46, Construction Fees/Building Permit Fees in the hospital column we are talking about something that comes under OSHPD. I don’t think that we actually do the plan check and inspection on hospitals so I don’t know if that is appropriate in there because it is not something that we will be mitigating or managing. Mr. Williams: Some of them may not be but it is a broad category and there may be some that are and then we have the Development Agreement that is an opportunity if we think there are certain stafftime being spent on processing these or one way or another is an avenue to use where maybe because of OSHPD we wouldn’t be able to otherwise. I don’t think this is intended to imply that on the hospital we are going to assess building permit fees because obviously they don’t have to go through that process. There are other uses as part of the Medical Center project that is not hospital basically the Hoover Pavilion site that is office buildings. Commissioner Lippert: I was going to get to that next. I was going to borrow Commissioner Sandas’s two-edge sword. Since Stanford Shopping Center was built it has been leased to Simon Group I believe. Simon Group is a profit-making entity. Any improvements that are done on that site I don’t know if they would be subject to improvements to property therefore subject to property tax. My understanding is that a lot of leases are done which are triple net in which case the tenant is paying property taxes as part of their lease arrangement. Since Stanford is a nonprofit I wonder how that is all being managed and that should be looked at. The flip side of that would be an rehabilitation of historic structures such as Hoover Pavilion would be subject to the Mills Act and therefore any improvements that are put in even for profit making would represent no increase in property taxes. So that should also be identified and just looked at. Ms. Silver: Just as a clarification, the City is preparing a Fiscal Impact Study and the itemization of these particular fees are meant primarily as placeholders and we will be looking at obviously all of those issues in the Fiscal Impact Study. Chair Holman: Vice-Chair Garber. Vice-Chair Garber: On item number 39 under M, I would like to add reliability and capacity to the first line so it is ’Reliability and Capacity of Sewer Water Improvements.’ Page 54 1 2 3 4 5 6 7 8 9 10 ll 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 3O 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 This gives us the opportunity if there are infrastructure improvements that need to happen to the water lines that have impacts to streets that lead up to the hospital. Chair Holman: Commissioner Keller. Commissioner Keller: l am not sure where this fits. What I am wondering is I want to make sure that the Development Agreement does not preclude Site and Design Review on the buildings as they come to be designed and built. That may not apply to the hospital but there are a lot of buildings that aren’t the hospital that apply and to the extent that we have Site and Design Review on these and more detail, to the extent that we have ARB and things like that we want to make sure that it goes through that normal process even though there is a Development Agreement. Chair Holman: Commissioner Burt, do you have any more comments on this? Commissioner Lippert. I have just a couple more to add. I support Commissioner Burt’s comments about the mitigation versus accepting fees. It seems like whenever we accept fees we are always taking it in the short end is how that seems to happen especially when it comes to housing. I understand that the City is going to be doing a Fiscal Impact Report. It should be considered that under Hotel, T, it has Transient Occupancy Tax Revenue. That is a benefit to the City. This is really more of a Development Agreement comment but it should be remembered that the shopping center expansion, the hotel, is a benefit to the City fiscally, it is also a benefit to Stanford and Simon. So that should be a part of the mix so ! am just making sure that that’s in there. On 54, please add Town & Country Village to that location. Item number 50, Vesting of Fees, ! guess this is something that has come up in the past perhaps with other projects. Personally ! think that that should go away because cost of delivering services including project review always goes up so vesting of fees I would suggest eliminating. Another piece of the fiscal impact has to do with services so if services have to be expanded like utilities, facilities, and staffing that should all be considered as part of the fiscal impact. Another Development Agreement comment on the Stanford Mayfield project the developer was given preferential access to utilities. Given this is such a large project and we have some aging infrastructure ! would not want to see that come forward again. Number 59, Location/Placement of Hotel, as Commissioner Lippert reminded us earlier there was a suggestion earlier that the hotel might be better located at Hoover Pavilion. So if you could add the X to SUMC to item number 59 that would be great. Commissioner Lippert: Correction, that was Commissioner Keller who had made that suggestion originally. Chair Holman: Understood but I thought you referenced it earlier. Commissioner Keller. Page 55 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Commissioner Keller: With respect to Utilities I am not sure where this fits. To the extent that there is an increased base load on utilities particularly electric utilities and that forces the utilities to purchase power on the spot market, the spot market may higher when you get over the base amount allocated to us, and that may have an effect on utility rates to other customers. I don’t have the solar panels yet ! am planning to. ! am wondering when is the appropriate time to talk about a process issue. Chair Holman: As soon as we have collected all the comments on these items. I don’t see any more. Commissioner Burt, did you have any more comments? So I think we can open the floor to comments about process, we could also open the floor to comments if there are any having to do with Attachment B, C, F or any other general comments that you care to make. Commissioner Keller. Staff, do you think you have everything you need from the list? Okay. Commissioner Keller. Commissioner Keller: I have a suggestion about process. It seems to me that there needs to be in my opinion a segmentation of the EIR and Development Agreement process that allows for appropriate inputs at the right time. So I would suggest that we have a six-step process. The first step is to have feedback to the Commission and Council on the data regarding the impacts as they are calculated. As part of that the Commission and Council suggest mitigations to be studied as part of the EIR process and at a midpoint so that we don’t wait until the DEIR, which is the third step, so the DEIR process has studied mitigations but we have an opportunity to propose mitigations based on the impacts and that would be in some sense the impacts would be decoupled from the DEIR if there is a midpoint in there. Next we evaluate the DEIR by making comments that is the fourth step. The fifth step is tO produce the FEIR, which gives the final environmental review based on an evaluation of the impacts and mitigations and that evaluation in the FEIR then we finalize the Area Plan and Development Agreement but we don’t do it concurrently with completing the FEIR. So the two important points I am trying to make is one that there be a midpoint in the DEIR process where we have data on impacts and proposed mitigations and the second thing is that the FEIR be completed prior to the Area Plan being finalized and the Development Agreement being signed. Mr. Williams: Could I ask one more time for one, two three? One was the feedback on the data regarding impacts. Commissioner Keller: Yes. Mr. Williams: So two is suggesting mitigations in response to that? Commissioner Keller: To be studied. Mr. Williams: To be studied as part of that. What was three? Commissioner Keller: Three is the DEIR. Page 56 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 4O 41 42 43 44 45 46 Mr. Williams: The DEIR itself and four is evaluating the DEIR. Commissioner Keller: Right. Fifth is the FEIR is released and sixth is the Area Plan Development Agreement occurs. I think this segmenting allows for appropriate input from the Planning Commission and the City Council and members of the public into this process that the lack of segmentation would forestall. Chair Holman: Vice-Chair Garber. Ms. Silver: I’m sorry, ifI could just comment on that a bit. That is largely the process that is setup and it is a very logical sequence and ! think that generally is reflective of the schedule. There of course is some overlap in terms of mitigation measures and community benefits and that type of thing. To the extent there is that overlap it could be beneficial to combine some of those steps. So for instance housing to the extent that is considered a community benefit versus a mitigation measure or vise-versa there may be some benefit in analyzing the impact of that housing in the EIR process. So there certainly is an overlap that will occur in the process. Commissioner Keller: I would certainly agree with the idea that when the proposed mitigations are studied that the collateral impacts of those mitigations also be studied in conformance with that. I just want to make sure that we have a midpoint of receiving the data on impacts and an opportunity for the Commission, the Council, and the public to understand those impacts and thereby suggest the mitigations to be studied. I have seen a lot of EIR processes in which that midpoint was not done and considering that this is a long Development Agreement process that would be unfortunate to be locked into mitigations that the community did not have an opportunity to suggest. Chair Holman: Vice-Chair Garber. Vice-Chair Garber: In general what I am hearing from Commissioner Keller is if there are opportunities for the public to participate further than what has currently been planned I too would encourage that participation. I would look to see a proposal from Staff because until I sort of see it drawn out or some diagram of it it is hard for me to sort of get my arms around it. Somewhat related to that, my comment is we had discussed at some length at the beginning of this process the sequence it would take and we had come up with and had given our endorsement to the schedule of tasks that we have been working towards. It may be appropriate to review those relative to some of the public comments that have come out. I am not asking for an answer now but perhaps if only for the Commissioners to remind ourselves what the logic was that we had now nearly a year ago. 1 actually have three other comments. I can relinquish and come back if you would like otherwise I can continue. Page 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 My other comments are not specific to the Issues List here but are broader but do address some of the issues of the EIR. Before I get to those two my third comment is really about the urban consultant that is coming on board. I would hope that that consultant is being brought on board with a somewhat different expectation than the hospital consultant in that there is an opportunity for that consultant to do more than just simple analysis but also to make suggestions, recommendations at both a smaller scale as well as a larger scale and that we could utilize this person not only for evaluation of what Stanford has done but also for what they can do. My last two comments I suspect that the section in the EIR that is dedicated to alternative projects being considered may end up needing to be more expanded than EIRs that this Commission has seen to date in order to capture a variety of different imagined projects all the way from not just no project but potentially no hospital which was quite interesting whether that would actually occur there or not. There are a lot of different variations and I don’t mean to say that the EIR needs to capture all of them but it may be that there are more scenarios that do need to be mapped out in order to make sure that they are all fully considered as possible alternatives. Finally, a process piece here. This Commission has benefited from the input of the hospital consultant and soon will benefit from the urban consultant. It occurs to me that it may be that the ARB might benefit from a heightened opportunity for additional consulting to the work that they do. What I am thinking here is specifically not necessarily a consultant but potentially a subcommittee, it may be a group of consultants that is really looking at and has a slightly broader opportunity to react, respond, suggest to the actual architecture of this particular project. Not that I want to usurp what the ARB’s role is but find a way to enhance it given the likely impact that this project and its size will have on this community. This would be a potential opportunity for a greater part of our citizenry to participate potentially in that project as well as to help ensure that we get the highest quality project that we can possibly get out of it. Thank you. Chair Holman: Commissioner Lippert. Commissioner Lippert: I want to go back to the issues and community benefits and mitigations list for a moment. ! have something to add to that. I alluded to this earlier. Stanford Medical Center at some point had tried to do a merging with UCSF. My understanding is that it didn’t work but Stanford Medical Center is somewhat fluid in terms of how they go about doing business. One significant community benefit that is not included on this list is really them being a not for profit hospital. I think that is a real important community benefit. What that lays down, and I alluded to this before in my line of questioning with the consultant earlier, there are a certain number of expectations with the hospital being a not for profit hospital, service that they have to provide this community, things that have to be maintained in operation continually, even the form of payment and the way the accepting of benefits from members of the community. I think that really has to be included in the Development Agreement that regardless of what happens that Stanford University Medical Center has to remain as a not for profit entity in order to be able to provide those services to our community. Page 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 In addition to that through the testimony that we have heard here tonight and some of the discussion and questioning Stanford does unfortunately have to turn some people away and I think it would be unfortunately if Stanford had to turn away members of our community that were in need of a hospital. It does two things. Number one this ceases to be a community hospital in some ways. Also those individuals would need to seek treatment in other areas thereby the impacts that we are trying to mitigate here are then thrust upon another community. So I would ask that in us putting together the Development Agreement that it be looked at that there are some resources that are allocated specifically for the members of this community. So those are two things that ! think could be included on that list. Chair Holman: Commissioner Sandas. Commissioner Sandas: ! am not sure that this goes on any list anywhere but what I would like to see in the DEIR when we get that far, my needle is stuck in traffic mitigation, I would like to see some real measurable traffic mitigation plans. Not just suggestions of things that might work like oh, expand the shuttle but in expanding the shuttle service I would like to see that in detail in terms of where, how, how often, etc. I would also like to see projections of traffic impact at key intersections within Palo Alto. Housing on campus is great. Housing near the hospital I am all for that but I would like to remind us when we are looking at traffic that we realize for every housing unit that is created several car trips per day are generated that are not work-related. So I think that needs to be factored into our equations and it probably is but I am not aware of how that process is run. More and more frequent public transportation doesn’t necessarily mean people are going to ride it. So in the DEIR I would like to see some suggestions for how to encourage greater ridership whether that is with the carrot or with the stick or a combination of both. I would like to see some ideas about that. Also, while we have been on the subject of the hospital all night and we haven’t really talked much about the shopping center I think that the shopping center has the potential for creating the greatest traffic issue in this whole project since there are more people who are coming from throughout the region and the idea behind expanding the shopping center is to make it regionally competitive with places like Santana Row and other places. So with that in mind it is pretty clear that people are going to be coming from other places besides Palo Alto and Menlo Park to shop in the Stanford Shopping Center. Also, bearing that in mind people will probably be coming from more places than just Palo Alto and Menlo Park to work there. So I would like to get a handle on where people are coming from who will be working in the shopping center when it comes time to discuss the center. Also, what measures can be taken to get shoppers not to drive but to us public transportation of some kind as well. I think that is going to be a real difficult task. If we are in fact committed supporting the GUP and the no net new trips I think that is going to be a real thorn that we have to deal with. I am not quite sure where that goes on your list of things but I wanted to say that. Page 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 Chair Holman: Commissioner Keller, you had something else to add? Commissioner Keller: Yes, in follow up to Commissioner Sandas’s comment about public transit ridership it might be worthwhile exploring at some point perhaps in conjunction with in a couple of weeks when we discuss the bus service in Palo Alto to consider the cases of Boulder, Colorado and Los Gatos. That might be interesting. With respect to housing I just want to observe that in the near time several days ago there was a comment about housing being so short and expensive that Stanford decided to buy a house or two for use by recent hires in the athletic coach department. I think it would be worthwhile understanding clearly what the approval process is for the Development Agreement when we get to that point. Is it an up or down process? Is it released to the public and tweaked? Understanding that process would be helpful. I will close with one of my favorite hobby horses which is related to the transit center and the comments there will high speed rail coming hopefully to town one of these days my vision for intermodal transit center is a little different than the Dream Team. My vision is one like you would find in Europe with a center that has shopping at it, a hotel at it, car rental either long term car rental or short term like a zip car or something like that. I think that will be a destination for people to come and to me that is a much better use than using it for a handful of housing units that only benefits a few people. Chair Holman: Commissioner Burt, do you have anything else to add? Okay. I have a few final comments then. As City Staff has heard from me before I want to pony onto the comments of Commissioner Burt that if other jurisdictions have input it is very helpful for us to have that as it comes in or as we have our next meeting on it. Comments have been made by other Commissioners tonight and several members of the community about the Development Agreement and the negotiation of that. That was an issue for this Commission when we reviewed the timeline previously. Commissioner Keller just moments ago just mentioned also the Development Agreement not being finalized prior to the DEIR and I certainly concur with that and not delivered concurrently with the FEIR. I concur with Commissioner Garber’s comments about the design aspect. Again not to usurp the ARB’s role but also the opportunities that exist here are considerable. I would like response to the question that was raised by a member of the public earlier who talked about Comprehensive Plan projections and we are superseding those. We didn’t ask for this previously and I am wondering if it is something that we can do. When we looked at the E1 Camino Design Guidelines we looked at narrowing E1 Camino in some places and adding different aspects of the roadway for various design improvements. What was provided at that time was also a model, a computer model, of Page 60 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 roadway movement. I am wondering if there are locations that that would be helpful for this to be able to understand and comprehend what the impacts are and how mitigations would work or not. 1 have to backup on myself here, one fiscal addition is that if there are to be any mitigations that are proposed to not be mitigated by the applicant that the fiscal impact of those also be evaluated for the community. Three last things. One is that mitigations in the Development Agreement, mitigations should be in place prior to or current with development. And four that the Development Agreement look at, most especially for the shopping center and the hotel, look at first source hiring. I have brought this up in the past and ! think this Development Agreement for especially the shopping center and the hotel are very good opportunities to do that especially with the housing opportunities. Then lastly, if Staff could identify what will be delivered to the Council as a result of this meeting. Mr. Williams: What I will have to sort of discuss is number one we will have the minutes, draft minutes ready for Council. What we will probably try to do with this is organize the comments you made on all those issues to sort of track down the Issues List as it is now with this comment was elaborating on this point or something or this one was suggesting a new issue for that category or something like that. So we will provide that whole list to the Council as your suggestions for modification, clarification, and elaboration on the list. That will be an attachment to the Staff Report. We will try to get that done by next week. It has to go out on Wednesday and be done on Tuesday since we have a short week. Chair Holman: Could that be emailed to the Commission so we can review that? Mr. Williams: 1 cannot promise that. It is going to be everything we can do to get that list done and in the packet. We will try to do that if we can. Chair Holman: Okay. So just to make sure ! am clear on that so what will happen is you will enumerate and categorize our comments by topic as they relate to this Attachment A. Mr. Williams: Right. Chair Holman: Great. Commissioner Lippert. Commissioner Lippert: I have a clarifying question. Stanford proposes a rezone on this so the rezone would be done parallel and as part of the Development Agreement. Can you clarify that for me? Mr. Williams: Yes, there is an action that ! am sure would be embodied in the Development Agreement. I guess it is not necessarily but yes there is a rezone to a new hospital zone which is what is being proposed and how that comes out remains to be seen. Page 61 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 Mr. Dan Deporto, Consulting Attorney: The rezoning would be simply one of the entitlements that is approved. There would be a General Plan Amendment, a rezone, approval of the Development Agreement would be a separate action, and the extent to which issues relating to the rezoning are covered or implicated by the Development Agreement it is pretty early to tell at this point in the Development Agreement negotiations. Commissioner Lippert: There are a couple of pieces to this and the reason why I am asking these questions. There are development regulations that would need to be drawn up. When we went through the Zoning Ordinance Update in particular the subcommittee went over seems like hundreds of different little criteria that fit into the development regulations. So those would need to be flushed out I guess prior to there being a zone and then applying that zone to the hospital. In order to do that we would need to see what their plan is in terms of height, density, and all those things. So I guess my real question is it is not really identified in the schedule how would that plug into our timeline. Mr. Williams: I think it is something that kind of fits probably between...a lot of these things are all kind of going along. There is development of the EIR, there is some initial discussions about the Development Agreement, the EIR comes out, and then we get down to the details of the Development Agreement. Somewhere in that midpoint probably we will have had drafted kind of the skeleton for what a zoning district might look like. I am sure we will then have meetings with you about if you wanted to have a committee that will help work through that or just come to the full Commission to go through some of those specifics and we do that before we package it all together with the other entitlements that are being requested. So it is kind of parallel with everything else but as Dan mentioned there is separate and as you mentioned there is sort of a discreet task there that needs to be done and it is obviously worthwhile visiting with you about that. It needs to be late enough in the process so that we don’t really nail it down until these other decisions are made too. So everything kind of converges at one point with the EIR mitigations and the Development Agreement and the zoning being finalized together or close to together. Commissioner Lippert: Well, I guess the question that I am asking here is that when we go through a PC process there are development regulations associated with PCs and those are sort of flushed out while the PC is put together. Since a Development Agreement is similar although there are impacts outside of the actual land that the Development Agreement pertains to, the actual development on that site, is it possible to go through and do the rezone as a portion of the Development Agreement or is that saying there is just too much going on here? Ms. Silver: Typically it all happens together although there is that logical sequence that Commissioner Keller laid out but at the end of the process the Final EIR analyzes the zone change and the Development Agreement and any other entitlements that will be required to approve the project. There is that overlap and that delicate balance and Page 62 1 2 3 4 5 6 7 8 9 10 11 12 13 typically we do have parallel process for many of the steps and then it all culminates at the end of the project approval and the final adoption of the EIR. Mr. Williams: It can’t be done with the Development Agreement because the Development Agreement is this document that sits outside of the Zoning Ordinance. So we refer to it for some of the specifics of these various tradeoffs, etc., vesting versus community benefits, etc. The zone change is in the Zoning Ordinance so that is going to stay there until however long in the future that gets changed. Until it gets changed by somebody it is there. The Development Agreement has a timeframe associated with it, certain specific things that have to happen. So you can’t really mix the two and put the zoning ordinance up in the Development Agreement. Page 63 Legend San Mateo County .... =~ Palo Alto City Boundary Stanford Lands Potential Housing Sites Area "B" (Portion excluding Golf Course) Special Condition-Sandhill Devt. Agmt. (Current zoning allows Housing) Potential Housing Sites and Potential Unit Yields 1 - PasteurANelch - (in CPA) approx. 100 Units 2 - Quarry/Arboretum (Site H in GUP) approx 200 units on 8 ac Quarry/El Camino (Site I in GUP) approx 200 units on 8 ac 4 - Transit Oriented Housing (in CPA) approx 30 units (Rezoning required) 5 - Area B (portion, excluding Golf Course) Residential Density to be determined C - EscondidoVillage: infill (GUP) approx 1,145 units on 116.5 ac F - Driving Range (GUP) approx 102-195 units on 17.5 ac G - Searsville Block - w/removal of units (GUP) approx 380 (-13) units on 12.8 ac 0 - Stable Site (GUP) approx 200-372 units on 24.8 ac Attachment D The City of Palo Alto This map is a product of the City of Palo Alto GIS Attachment E STANFORD UNIVERSITY MEDICAL CENTER FACILITIES RENEWAL AND REPLACENIENT PROJECT ENTITLEMENTS This document lists the City of Palo Alto approvals and entitlements that have been identified for the SUMC Facilities Replacement and Renewal Project. In order to simplify review of this document, each specific proposal is presented in italics. As the project approval process progresses, additional entitlements may be identified, and some of the requested entitlements may be modified. EIR Certification and CEQA Findings Prior to approval of the proposed development project at SONIC, and supporting land use entitlements, the City will need to complete environmental review under the California Environmental Quality Act, and adopt written findings. Based upon the anticipated environmental effects of the proposed project, CEQA review will be performed in the form of an Environmental Impact Report, and the E1~R will address both the proposed project at the and Simon Properties’ proposed project at the Stanford Shopping Center. Comprehensive Plan Land Use Designations The Comprehensive Plan designates the portions of the SU~fC that are within the project boundaries "Major Institution/Special Facilities," "Research/Office Park," and "Major InstitutionfUniversity Lands/Campus Educational Facilities." (See Figure 1-2a for a depiction of existing Comprehensive Plan designations.) The Major Institution/Special Facilities desig-nation contemplates the following uses: Institutional, academic, governmental, and community service uses and lands that are either publicly owned or operated as non-profit organizations. Examples are hospitals and City facilities. (Comp. Plan pg. L-12). The Research/Office Park desig-nation allows office and research establishments, as well as educational institutions. (Comp. Plan pg. L-12) The Major Institution/University Lands/Campus Educational Facilities designation applies to academic lands of Stanford University within Santa Clara County. The Comprehensive Plan reports that allowed uses within this designation include academic institutions, research facilities, student and faculty housing, and support services. (Comp. Plan pg. L-13) As shown on Figure 1-2a, most of the SUMC property inboard of Welch Road fits within the Major Institution/Special Facilities designation, corresponding to the area upon which the existing hospital facilities are located. Over time, properties in the SUMC have been added to this land use desig-nation to reflect changes in their use as hospital-related facilities. Most recently, in 2000, in connection with the City Council’s approval of the Center for Cancer Treatment and Prevention/Ambulatory Care Pavilion, the City amended its Comprehensive Plan Page 1 of 8 to include 1101 Welch Road and the Blake Wilbur Clinic within the Major Institution/Special Facilities land use designation. Figure 1-2b depicts proposed Comprehensive Plan changes for the SUMC. As part of the proposed project, LPCH proposes to construct hospital facilities on the properties located at 701 and 703 Welch Road. Accordingly, LPCH proposes as follows: LPCH proposes that 70J and 703 Welch Road be brought within the "Major b~stitution/ SpeciaI Facilities’" land use designation. This would be consistent with LPCH’s proposal to consrr~ct new hospital facilities on those properties. In addition, the project includes a small boundary change at the southwest coruer of the project boundary in order to accommodate the footprint of one of the proposed SoM buildings. Prior to initiation of this boundary, change, SUMC proposes that the Comprehensive Plan designation of the site to be annexed be changed tO make it consistent with the adjacent property inboard of Welch Road. SoM proposes that the City designate the small site inboard of Welch Road that is proposed to be annexed as "Major Institution/Special Facilities." The Comprehensive Plan also designaates the Hoover Pavilion site "Major Institutional/Special Facilities." SHC leases and uses Hoover Pavilion for clinical, research and hospital-related purposes. The SU~IC Facilities Replacement and Renewal Project includes construction of two new buildings and associated paring at the Hoover Pavilion site to provide building space for corm-nunity practitioners, medical offices for Stanford-affiliated physicians, SHC clinics, hospital Health Education Progams, administrative and operational support for medical office practices, and other hospital-related uses. No Comprehensive Plan change is requested at this site. The project does not include changes to the Research!Office Park designation except to remove 701 and 703 Welch Road from this desig-nation, as described above. Goals. Policies and Pro_~rams The draft Area Plan Update reviewed by the Planning and Transportation Commission in June, 2007 and accepted by the City Council in July, 2007, identifies a number of Comprehensive Plan goals, policies and progams that apply to the SLrMC. The Area Plan Update explains how the project is anticipated to further the Comprehensive Plan’s objectives. During initial discussions, City staff has identified one Comprehensive Plan program for potential amendment. Comprehensive Plan Pro~am L-3 states: Maintain and periodically review height and density limits to discourage single uses that are inappropriate in size and scale to the surrounding uses. The proposed project includes structures that will be taller than current height limits established by the existing zoning. As explained below, the hospitals and SoM propose that the City review Page 2 of 8 its height and density limits for the SIJ~’-ZvIC as part of its consideration of the project. The City’s review and approval process will ensure that the proposed structures will not be inappropriate in size and scale to the surrounding uses. Therefore, the proposed project is not expected to be inconsistent with Program L-3. The Comprehensive Plan text located beneath Program L-3, however, refers to the City’s existing fifty foot height limit and reports that recent development proposals largely have conformed to that limit: The Citywide fifty foot height limit has been respected in al! new development since it was adopted in the 1970’s. Only a few exceptions have been granted for architectural enhancements or seismic safety retrofits to noncomplying buildings. If the City approves the requested zoning change described below to allow taller buildings within the SU~/IC, the City also could reflect this change in the discussion beneath Program L-3. It is proposed that the text beneath Program L-3 be modified as follows: The Cirywide fifly/ foot height limit has been respected in all new residential and commercial development since it was adopted in the 1970’s. Only a few" exceptions have been granted for archirecutral and enhancements or seismic retrofits to noncomplying buildings, hz addition, the City has allowed taller buildings ~t.’ithin the Hosz)ital zone at the Stanford Universi>., Medical Center that reflect the Medical Center’s unique needs. Zoning Zonin ~ Districts Figure 1-3a depicts existing zoning districts for the project sites. Corresponding to the Comprehensive Plan categories described above, two City of Palo Alto zoning desig-aations apply within the project boundaries. The Public Facilities (PF) zone applies to the properties designated ’°Major Institution/Special Facilities" by the Comprehensive Plan. This zone includes most of the in-board Welch Road properties (801 Welch, Cancer Center, Blake-Wilbur, Parking Structure III, 1101 Welch, Parking Structure IV, the adult hospital, and the Lucile Packard Children’s Hospital), and the Hoover Pavilion. The Medical Office and Medical Research (MOR) District applies to the properties designated "Office/Research" by the Comprehensive Plan. This includes the out-board Welch Road properties (730,750, 770,780, 800, 900, 1000 Welch) and some of the in- board Welch Road properties (701,703,777 Welch). Other than a boundary change for 701 and 703 Welch Road, the project does not include any proposals to change zoning within the Medical Office and Medical Research District. No changes in use are proposed within that district, and any development activity within that district would be consistent with current zoning standards. Page 3 of 8 The proposed development of new medical center facilities in-board of Welch Road and at Hoover Pavilion would necessitate amendments to the current PF zone. While the uses proposed at these sites are consistent with uses conditionally permitted under the PF zone, the proposed additional square footage and building heights would necessitate modification to the PF zone’s development standards. The Palo Alto Zoning Code states that the existing PF public facilities district is "designed to accommodate governmental, public utility, educational, and community service or recreational facilities." Private educational facilities, hospitals, and outpatient medical facilities with associated medical research are conditionally permitted uses. A new or amended conditional use permit is necessary for expansion of a building site or area. Current PF development standards include: The maximum Floor Area Ratio (F~’-MR) is 1 to 1 (i.e., 1 sf of development per 1 sf of land area). On the Hoover Pavilion site, the FAR is .25 to 1. The maximum site coverage is 30% of the site area; however, for par’king facilities the maximum site coverage is equal to the site coverage allowed by the most restrictive adjacent zoning district. The maximum height is 50 feet. Sites abutting or having any portion located within 150 feet of any residential district are subject to special requirements. Parking requirements are established in Zoning Code section 18.83. For a hospital, the requirement is 1 space for every 1.5 beds; for medical offices, the requirement is 1 space for every 250 square feet of gross floor area. It is possible to defer up to 20% of the required par’king based upon a showing that alternative transportation programs will reduce demand. At least a 20 foot street setback (yard) is required. M_inimum setbacks are equal to the setbacks in the most restrictive abutting district. Sites abutting a residential district must have a solid wall or fence, and a 10 foot interior yard planted or maintained as a landscape screen. Sites opposite from a residential district and separated by a street, drainage facility or other open area, require a minimum yard of 10 feet, ptanted and maintained as a landscape screen. Generally, use permits require that parking be maintained at quantities necessary to meet zoning requirements. However, in recognition that there is no formal distinction between hospital and campus parking and that the medical center spans two jurisdictions, use permits in the SUMC have allowed for a regional parking approach that relies on parking in both City and County locations, i.e., not assig-ned on a building-by-building basis. Table 1-!, which follows this document, identifies the existing square footage and footprint of SUMC structures within the PF zone. The table shows that existing structures on the PF-zoned area inboard of Welch Road total 2,189,018 square feet on a site that is 2,198,082 square feet in size. As a result, only a very small amount of additional development would be allowed under Page 4 of 8 the current F,e~aR of 1.0. Table 1-1 also shows that the estimated footprints of structures on the PF-zoned area parcel inboard of Welch Road total 649,424, again providing room for only a small amount of additional development within the existing 30% site coverage requirement. Similarly, Table 1-1 shows that existing structures at the Hoover Pavilion site occupy the entire amount of the 0.25 FAR allowed on that site. Table 1-2 identifies the square footage and footprint of proposed and retained structures within the existing PF zone under the proposed SL~’IC Facility Replacement and Renewal Project. This table indicates that, to accommodate the proposed project, the FAR on the inboard Welch Road area would need to be at least 1.42, and site coverage would need to be at least 0.36. Table 1-2 also indicates that to accommodate the proposed medical buildings at the Hoover Pavilion site, the FAR on that site would need to be at least 0.75, and site coverage would need to be at least 0.~_. In addition to changes in FAR, the proposed project would necessitate changes to the height limits in the zoning district. Under the proposed project, some structures proposed on the inboard Welch Road area would be as tall as 130 feet. Structures proposed on the Hoover Pavilion site would be as tall as 60 feet. As explained further in the accompanying project description, these changes in development standards are related to specific drivers applicable to hospitals and medical research facilities. Accordingly, it is proposed that rather than amend the PF zone citywide, the City initiate creation of a new zone that would apply only to hospitals and associated medical research, medical office, and support uses. Given the uniqt~e nat~tre of the SUMC, and the needs particular to provision of healthcare in a hospital environment, it is proposed that the Ci~’ initiate approval qfia new zoning district that ~’ould include development standards designed to accommodate the proposed project, as well as to provide for flexibilit), in ongoing project design and enable a relatively minor amotmt of potentiaI fi~tt¢re expansion. The key components of the new district ~.vo~dd be as folIo~vs: The new zoning district wo~dd have its o~vn name, such as "Hospital District" or "P~blic Facilities/Hospital District." Permitted ~tses would include: private educational facilities; private zmiversities; hospitals; outpatient medical facilities; medical research; medical offices; medical s~pport se~’ices; retail services in conjttnction with a permitted use; eating and drinking se~’ices in conj~mction with a permitted use; and accesso©" facilities and activities c~,.stornarily associated with or essential to pe~witted ~ses, and operated incidental to the principal use. As long as.proposed uses are consistent with the zoning req~drements, projects developed on these sites ~vottId be subject to design review and approval by the ARB, but ~votdd not req~dre a conditional use pe~v~zit. Page 5 of 8 The maximum FAR for the inbo(zrd Welch Road area would be 1.5 to 1. FAR would be calculated based upon the total contiguous area within this zone, rather than on a parcel by parcel basis. The maximum FAR for the Hoover Pavilion site would be 0.75 to 1. 77~e maximum site coverage would be 40 percent of the site area. Parking facilities would not be counted in deter~nining site coverage. Site coverage would be calculated based upon the total contiguous area within this zone, rather than on a parcel by parcel basis. The maximum height on the inboard Welch Road area would be 130feet. ~_e!ght on the Hoover pavilion site wo~dd by 60feet. No yard adjoining a street would be less thanJO feet, measured from the curb to the base of the buildings and no bzchtding any awnings or other projections. This setback requirement does not apply to beiow-grade parking facilities. No standards would be specified for site area, site width or site depth. Regulations governing accesso~2" faciIi~ies and uses, and govervzing the application of site development regulations in specific instances would be esrablished by Chapter 18.88. Parking requirements would be perfo~vnance-based, as eL’ablished by the ARB during review of project design. Parking would be provided to meet projected needs, with consideration given to the potential for reduced parking demand due to the proximity of the Palo Alto bxte~vnodal Transit Station (PAITS). Zonin_~ Boundaries Figure 1-3b depicts proposed zoning boundary changes within the project boundaries. As explained above, the proposed project includes construction of hospital facilities for LPCH on the 701 and 703 Welch Road sites. These sites are inboard of Welch Road and adjacent to the area currently zoned PF. K re-zoned, they would be treated as one planning area with the remainder of the inboard Welch Road properties (except for 777 Welch) for purposes of calculating compliance with the zoning standards. LPCH proposes that 701 and 703 Welch Road be brought w~thin the Same zoning designation as the other inboard Welch Road properties (i.e., rezoned from MOR to the new zone discussed above). In addition, the proposed project includes development of a small additional site outside of the City limits, at the southwest comer of the project area, to accommodate SoM’s proposed facilities. It is proposed that this site be pre-zoned consistent with the adjacent property inboard of Welch Road prior to initiation of annexation. It is proposed that, prior to annexation, the Cir, pre-zone the small site at the southwest comer of the project area that is proposed to be annexed to the Ci& by applying the same zoning district as the inboard Welch Road properties and the Hoover Pavilion site to this site. The site Page 6 of 8 r,o be annexed would be treated as part of the same planning area as the remainder of the inboard ~lch Road proper-ties for purposes of calculating FA_R and site coverage. Jurisdictional Boundary Change Figure 1-4 depicts the site proposed for annexation to the City’ of Palo Alto. The cu~ent placement of the jurisdictional boundary between the City of Palo Alto and Santa Clara County along the southern edge of the SU,~’MC bisects the optimum proposed site for the SoM’s FErvl #1 building. Accordingly, SoM proposes a minor adjustment to the City-County line in this location. SoM proposes that the CiU initiate annexation of the small site shown on Figure 1-4. Prior to initiation of annexation, SoM proposes that the Cizy pre-designa~e in its Comprehensive Plan and pre-zone this site, as described above. Architectural Review Under the proposed new zoning district, Architectural Review Board approval would be needed for development of the proposed project. The hospitals and School of Medicine plan to seek prelimina©, ,4_gB review and will request ARB approval of their proposed facilMes. Subdivision/Leasing No subdivision or lot line adjustment is proposed at this time; however, it is possible that that such approvals would be sought in the future. Such changes would not affect the development potential of any of the areas within the project boundary. It is noted that the APN lines shown on Figure 1-5 do not necessarily reflect legal lot lines. At many locations on the Stanford campus, APN lines have been drawn by the governing agencies for convenience, however there are few, if any, legal lot lines. Figure 1-6 depicts the boundaries of existing leaseholds within the project boundaries. As shown on this figure, some of the existing leases match the assessor parcel boundaries shown on Figure 1-5. Other existing leases, such as SHC’s lease for the medical center complex, are footprint leases or are footprint leases with limited extensions. SHC’s lease for Hoover Pavilion also is a footprint lease. The existing lease lines may be modified to reflect the footprints of the proposed buildings prior to construction and ~ccupancy of the buildings. Development Agreement A development a~eement is desired in order to achieve the hospitals’ objective of optimizing the delivery of healthcare and services to their patients. A development a~eement would ensure that the approvals ultimately obtained will remain in force and unchanged during the lengthy Page 7 of 8 Attachment. G Discussion Summary Stanford Project Communi~ Meeting- Land Use and Housing October 4, 2007 Land Use Comments What are the points of input from citizens? Area Plan Zoning Development Agreement Project submittals and Impact Fees- can an impact fee be imposed or grandfathered? Development Agreement can contain provisions for requiring fees What are the stages of construction!development? Stanford Hospitals and Clinics and LPCH- add over one million square feet up to 2025 Community practioners space Promote space for community practioners Hoover Pavilion would contain approx. 40,000 square feet of office moved from 1101 Welch Road Ne~v construction of approx. 200,000 square feet adjacent to Hoover Pavilion Ask current Doctors how it will work for them to move to another space *Size of the hotel-project should contain provisions for future expansion of the hotel ~Building heights as proposed are okay-- smaller building footprints would allow more open space ~More tax revenue from sale at shopping center is okay ®Village Residential concepts could be located near Hoover Pavilion in County land Housin~ Comments Development Impacts Fees? ~Vhy would SUMC be exempt? Why is Stanford required to provide housing outside of students and faculty? Where has city provided affordable units? Alma Substation is one example of affordable housing under development Income levels and impacts on rents from increased employment at SUMC and SSC Stanford University General Use Permit (GUP)- Requirements to add housing when academic space is developed. Should affordable housing be developed or fees paid to the City? Look at impacts on compliance w/AB32 Impacts on schools and roads; also need space for housing Housing is regional issue- Palo Alto’s share of housing should be analyzed Area near Hoover/E1 Camino Real (GUP housing site)- could this be used as a Village residential site? Additional housing increases traffic impacts- how will these be mitigated? Increased housing results in additional school impacts. Capacity study should be completed Family housing should be provided Consideration for the Comprehensive Plan update to allow housing in commercial & industrial land (W. Bayshore/E. Meadow Circle). These are potential housing site that should be studied. Discussion Summary Stanford Project Communi~ Meeting- SustainabiliD and Open Space October 18, 2007 General Comments- SUMC and SSC .Sustainability at medical facilities should promote equity and quality of life *Higher density not bad Not necessarily same as today Need to solve problems Promote transit opportunities o Understanding vehicle trips is important Encourage walking trips Shared use facilities to minimize trips Open Space and Height Tradeoffs- precedent for increased height? Examples at other hospitals? Tradeoff not needed for hospital- already enough open space on campus Success of open space- How useful and/or attractive is the open space? Open space provides relief to patients, visitors and employees Important to define functions Many opportunities for energy efficiency Efficiency for operational energy usage Energy efficiency helps Palo Alto Utilities Water efficiency opportunities Storm water drainage could be used for irrigation Grey water use Water crisis may require new solutions Segregate medical waste from recyclable Provide separate containers Employees should live near hospital facilities Vehicle miles for employees commuting to work should be understood Housing provided near hospitals East-West transportation in Palo Alto Light weight aerial (cable suspended?) personal vehicles Span Et Camino Personal Rapid Transit (PRT) Not necessarily a mitigation Partner w/community to create the system Energy cogeneration at the hospitals to reduce energy loads Rooftop turbines (micro turbines) Durability of structures Shoppin~ Center Similar to Santana Row- vertical, multiple uses including residential; keep hotel East-west transit in Palo Alto- Should be a component of the SSC project More future vision to address long term impacts such as global warming Eliminate free parking Manage existing parking better Housing for employees Reduced parking has effect elsewhere, such as adjacent residential neighborhoods Discussion Summary 5tanfor.d Project Community Meeting- Transportation and Linkages November 1, 2007 Ideas to reduce trips to the SUMC!SSC * An east-vv-est people mover a Park N Ride @ 101 & Embarcadero w/shuttle ~ Reduced on-site parking and charge fees for parking . Off site parking mitigations, to/from airport, SLAC, East Bay ~ Carpool- Stanford should encourage as much as possible ~ Expanded Marguerite shuttle system Expand to Menlo Park . Underground facilities Parking, tunnels, etc- would be a safe alternative ~ Run long distance buses for employees living in outlying areas ~ Use of private cabs instead of transit ~ Fleet of bicycles Special lanes- bicycles, scooters, buses Conveyor for shopping items ~ Identify incentives/disincentives for reducing vehicle trips ~ Solutions should not include more road & parking spaces ~Cost of parking is extensive ($20K-50K per space) - put into shuttle or other measures How do people get to hospital now? .Focus on Highway 101 and E1 Camino Real- how would these highways contribute to traffic? .Project may result in increased traffic from relocated medical offices- keep them nearby ~How- much of traffic to SUMC & SSC from employees, v. patients and v. shoppers? Stanford traffic study in the application materials ® Does not address impacts on intersections ® Does not address capacity issues . Question the credit for right sizing Paid parkin__, at SSC ®How would paid parking work for customers visiting a shopping center? Perhaps it would work or employees .Santana Row- Some paid parking will be coming online soon ~Cost of these measures- economic studies .Offsite parMng for SSC Reduce traffic to!from and within Palo Alto ~ Locations for housing should be close enough to avoid driving ¯ Caltrain- Long distance commuter solution- SSC could validate transit fares . Upgrade Caltrain to be more convenient ~ Caltrain Depot status funding Long term project . Promote better transit connections to other Palo Alto areas Chan,oes of travel modes/lifestyle/over course of project How-does downturn in economy affect project? What new- roadways proposed or needed? Connection between Sand Hill/Welch ~Look at impacts other than congestion -make positive- provide greener transportation. City of Palo Alto Intermodal Station- "Dream Team" . Design could be crucial ~ Increase walkability at transit center . Promote good synergy and connections between Dow-ntown, SSC, Town & Country and SUMC Research park- Integrate into parking s "Free" parking in neighborhoods near Research Park- creates impacts EIR-Greenhouse ~as impacts from transportation imapcts? . Emphasis on alternative modes to reduce car trips Any ~ood examples of alternative to get people to shopping center? *Shuttles like at amusement parks- connect shopping and hospital ~"Emery-go- round" in Emeryville, CA- Charge for parking in garages at Bay Street shopping center .Public transportation is often inefficient -depends on population density- too much time between buses *Other models- often shopping centers don’t like transit stops Other Conm~ents ®\Vhen analyzing trip from zip codes, be sure to divide 94303 zip between Palo Alto and East Palo Alto .How much traffic would come from Sand Hill Road vs. E1 Camino Real? .Methodology needs to be explained; EIR consultants need to provide independent analysis *Impacts of mitigations- would mitigations cause impacts? Impacts of mitigations need input now *Linkage of housing and transportation ATTACHMENT H k N !i’ ()1-{ 1) U N I V I:_R S I ] Y M E D I (:At.C I:: N I !-: Memorandum To: F rOITl: Date: Subject: City of Palo Alto Stanford University Medical Center (SUMC) November 7, 2007 Welch Road Community Health Care Providers [’he dislocation of non-Stanford comnmnity health providers as a result of the SUM.C Renewal and Replacement Project was discussed under tab 3 of tile Stantbrd University Medical Center Project Subrnittal Application first delivered to the City on August 13, 2007. As noted there (tab 3, pp 3 and 9). the hospitals maintain a strong relationship with community health care providers, particularly those whose patients also seek services fion~ tile medical center hospitals. Currently, many of these community heahh care providers lease space adjacent to tile SUMC in structures owned and operated by SHC, I~PCH, or private building owners. Tile SUMC Project includes the demolition of tlu’ee buildings on Welch Road that are leased in part to community health care providers: 70t. 703 and 1101 Welch. with a total of 52,975 sf currently leased to non-SUMC health care providers. Tile hospitals are identi[’ying alternative space lbr tenants of the buildings who will be displaced. Specifically, the health care providers who currently occupy the 30,100 sl" of leased space at 1101 Welch, all of whose leases now expire in 2009 and who require proximity to the hospitals., have been offered long-term leases for space at the existing Hoover Pavilion building at 211 Quarry Road, (Such leases wilt be at market rates as required by Federal legal provisions prohibiting hospitals fl:om discounting leases to practitioners who would be rel:’erring patients or business.) In addition, tim hospitals have master-leased approximately 40,000 siT of medical office space on Middlefield Road in Menlo Park, and the majority of flint space is dedicated to meeting the needs of the community heahh care providers who currently occupy the 22,875 sfof leased space in 701 Welch and 703 Welch Road, most of whom (dentists and others) do not require hospital proximity. Stanlord Shopping Center 180 Et Camino Real, M384 Mailing: 300 Pasteur Drive, MC 5788 ¯ Stanford, CA 94305-5788 ¯ 650-723-7447 ’ f: 650-725-5396 City of Palo Alto Re: Welch Road Community l-leahh Care Provklers November 7, 2007 Page 2 Together, the existing Hoover Pavilion building and the leased space on Middlefield Road ~vould accommodate most of’the health providers who will be physically displaced due to demolition of buildings for the SUMC project. Some community health providers have chosen to seek alternative premises on their own. In addition, in order to accommodate potential future growth in clinical and medical o~’fice services, and in order to accommodate those non-SUMC community health care providers who have expressed concern about needing long-term leases in the Medical Center area clue to potential lease expirations in other buiktings on Welch Road~ the hospitals are proposing post-2015 development of 200,000 sf of new medical office building space on the Hoover Pavilion site. Approximately 100,000 sf’ofthis space will be needed to support the hospitals and up to 100.000 sfcould be made available to community health care providers. This space is expected to be sufficient to accommodate all project-related needs for medical office space. Stantord Shopping Center "180 El Camino Real. M384 Mailing: 300 Pasteur Drive, MC 5788 ¯ Stanford, CA 94305-5788, 650-723-7447 ’ f: 650-725-5396 Attachment I _~xeeLldve Summ~ty Ev~iu~tio~ of P~oposed Stanford Me&’cM Center HospitM.~o~iects The CiD, of Palo Alto has commissioned a Peer Review of Stanford’s r, vo major proposed facility development projects: ~The renewal and replacement of the adult Stanford Hospital and Clinics (SHC) and The renovation of and addition to the Lucile Packard Children’s Hospital (LPCH). The Peer Review investigations are ,aimed at validating the need for the two projects and determining the extent to which the proposals fall within the norms of current-day hospital planning and construction, identifying areas of convergence with or divergence from these norms. The key issues addressed in the Peer Review investigations, and the conclusions reached., are sun’maarized below. The flail report presents and explains in detail the factors, benchmark data and observations that support the conclusions. At Bed Numbers - the fundamenta! "drive~’ of space needs Stanford’s proposed projects are for inpatient hospital expansions and improvements. The number of inpatient beds is the most basic space driver. The bedrooms themselves require space and the size of all the support services, from operating rooms to staff areas to food service and housekeeping, are based on the numbers and D:pes of patients being accommodated. SHC is proposed to increase from 456 to 600 beds (32%) and LPCH from 257 to 361 beds (40°/’0). The combined bed numbers will increase from a current total of 713 to a new total of 961, an overall increase of 35%. Source of bed numbers Stanford has done significant research and analyses on several levels to define the number of beds proposed for each hospital. Individual medical departments, the overall Medical Center, and Stanford’s Strategic Business development department all analyzed bed need. Two independent outside specialist consultants reviewed internal assumptions and data and developed bed number projections, and two separate planning fu:ms reviewed and confirmed the numbers, resulting in a consensus on the bed number projections noted above. Factors that influence bed number projections: a.Demographics - both an aging and a growing population. b.Disease tTpes and medical conditions - increases in acuW, multi-system problems c.Current occupancy rates - nearing 90% -- no additional capacity. i. SHC and LPCH are turning patents away due to lack of beds to put them in. d.ALOS (average length of stay) is no longer decreasing, as it was for maW years. e.Closure of other local hospitals creates regional pressure for more inpatient beds f.Increased focus on disaster preparedness and emergency response 11/7/2007 Peer Reviewer: ~4arlene j. Berkoff, FAIA Page 1 of 7 Conclusion: It appears that the bed numbers proposed for the new hospitals are supportable and that thorough analyses have taken place at several levels. The increase of approximately 35% for hospitals that were planned 25 years ago (SHC) and 20 years ago (LPCH) seems congruent with what might be expected, given the time lapse, the changes in demographics, the closure of other local hospitals, the advances in medical treatments and capabilities, the renowned expertise of SHC and LPCH, and the need to look to the future. Private Patient Bed Rooms A major factor in the size of the hospital projects is the fact that nearly all replacement and renovated patient bedrooms will be private, single rooms, each with its own toilet room. Bed Number Comparison The two hospital projects propose a major increase in the proportion of patient beds in single, private rooms. Overall, the tav’o hospitals will go from 35% single rooms to 89% single rooms. The shift from double rooms to singles creates a major space increase, even without the addition of more beds. Industry Standard is Single Patient Bedrooms Almost all nexv hospitals across the nation are being planned for single patient, private bedrooms, with individual toilet!shower rooms. This research found no hospital or consultant xvho was planning for other than private rooms or had done so in recent years. Reasons include a reduction of hospital-acquired infections and reduced likelihood of medication errors as well as a greatly reduced need for patient transfers due to inabilib~ to match compatible roommates (disease, age, gender). Single patient rooms increase bed utilization and operational efficiency and reduce patient fails and nurse injuries due to transfers. Finally, single patient rooms greatly improve patient satisfaction and are a dear nation-wide preference. Guidelines and References American Institute of Architect (ALR) guidelines, upon which most state codes are based, now mandate single patient bedrooms except in special cases for all new construction. CA is in the process of adopting these guidelines and anticipates doing so in 2008. Review of odaer hospital planning sources, from national documents such as the 2007 "Hospital of the Future, Lessons for Inpatient Facilib~ Planning and Strategy," to discussions with national planning and desig-n £m-ns, to many institutional healthcare providers, confirms that all recommend planning for single, private patient bedrooms. Numerous CA hospitals planned or recently constructed have used all single patient, rooms. (UCLA, UCSF, Kaiser and more.) Conclusion Given the pervasive attitude and evidence-based research favoring private patient rooms, it would be unreasonable to expect Stanford to plan for anything other than private patient rooms. Co Size of Patient Bedrooms Single rooms require more space per patient than semi-private rooms, plus each single room requires its own toilet/shower room. Patient bedrooms are the single most repetitive element in a hospital. Inpatient nursing units account for approximately 50% of the total hospital area for both SHC and LPCH. A shift from double to single rooms has a major space impact. 11/7/2007 Peer Reviewer: Mazlene j. Berkoff, FAL5 Page 2 of 7 Private Room Area Comparisons A comparative review of the size of recently planned and designed private patient bedrooms, including toilet rooms, was conducted. Data was obtained from several sources, including the national Health Care AdvisoU Board, Kaiser, UCL, R, UCSF, and a number of national planning and design firms representing numerous hospital projects. Observations and Conclusions: The size of patient bedrooms for both SHC and LPCH is programmed within the range of other peer institutions and is reasonable for any current-day hospital development. Academic hospitals D~pically require larger spaces than communitT hospitals, yet Stanford’s numbers compare reasonably with those of Kaiser as well as those of other academic teaching hospitals such as UCLA and UCSF. Operating Rooms (ORs), Emergency Department (ED) and Imaging Sen-ices Each of these ser~,ice areas represent a key space user and seta-ice component of the hospitals. Each is planned to expand significantly, primarily due to a projected increase in patient volume and acuiD~ and a dramatic increase in medical equipment and technologies in use today. In each case, there is a considerable space and capaci~, deficit already e:dstmg which must be made up, plus a veU important need for expanded capaci~" to accommodate nexv groxvth. As with patient bedrooms, each area was reviewed relative to comparable institutions and other CA hospitals. To the extent that comparable data were available, each was found to be consistent with areas planned for other academic teaching hospitals of Stanford’s size and level of care. (This applies to both SHC and LPCH.) Detailed reasons for the growth and needed space increases for each of these areas is included in the full Peer Review Report. Comments on ORs, Growth in Size of Operating Room Suites - °’Interventional Platforms" The size of operating rooms and associated support space has dramatically increased industtT-wide, and nation-wide, over the last decade. The OR is no longer a single room, but rather the hub of a complex array of interventional diagnostic and treatment seta-ices. Sophisticated medical equipment has prol~-erated, as has the number of staff and computer support equipment needed. The sizes of the ORs planned for SHC and LPCH are consistent with comparable rooms in other institutions. There are no reliable rules of thumb for the number of ORs relative to patient beds. SHC and LPCH are both quaternaU care academic teaching hospitals, with the highest level of acuit-y patients anDvhere. Surgeries performed in these hospitals are often more complex and take longer than in communi~, hospitals such as Kaiser. Stanford has done in-depth analyses of anticipated patient volumes, tF,2aes of cases, and utilization patterns, to determine the numbers of ORs it is proposing. Comments on Emergency Department ~D] Issues The Emergency Department at Stanford Medical Center is shared by LPCH and SHC, and is a Level I Regional Trauma Center, designated to provide the highest level of care for serious emergencies, traumas and extreme/mass disasters. Stanford’s Level I Trauma designation covers a multi-county- region, including the counties of Santa Clara, San Mateo (southern portion), Monterey, Santa Cruz and San Benito. 1/7/2007 Peer Reviewer: Marlene J. Berkof~ FAL&Page 3 of 7 Stanford is proposing a 33% increase in the number of ED treatment rooms - comparable to the increase in patient beds, as well as an increase in support space. This is driven by the rising acuitT of patients admitted, the current over-crowding (long waits and patients being diverted to other hospitals), the proliferation of sophisticated medical equipment, privacy demands of government regulations (HIPPA), and the need for disaster surge capad~. Sizes of proposed ED treatment spaces compare reasonably to those of other comparable institutions as well as to Kaiser. All treatment room spaces are being proposed as private exam rooms, not curtained multi-patient treatment bays, as is the current indust_D, standard. Comments on Imaging Department Growth and Change Of all the departments in a hospital, the Imaging Dept. (RadioloD7) has experienced the most extreme growth and change in equipment, technologies, new approaches and methodologies over the last decade. New medical devices, new treatment modalities and new diagnostic techniques and tools, have all contributed to a massive explosion in equipment, the need for space to accommodate it, and the growing technical staff to provide the services. Further, constant new developments dictate a need for space to allow for expansion and change, and infrastructure to support it. Observations and Conclusions relative to ORs, the ED and Imaging: In addition to the increase in anticipated patient volumes and inpatient beds, the explosion of technologies and applications of medical equipment and treatment capabilities are creating a whole nexv set of space and infrastructure needs for hospitals nation-wide that didn’t e:dst when SHC and LPCH were planned. The uncertaintT of new advances dictates that new hospital construction, especially in an academic teaching center like Stanford, should be prepared to accommodate as yet undefined new developments. On a room-by-room basis, specific rooms for each of the key areas, ORs, ED and Imaging, appear to be within ~pical norms for new hospital developments. This information is presented in more detail in the full Peer Review Report. Eo Overall Hospital Space Growth and Hospita! Size: Additional Factors to Consider In addition to the increase in space needs for specific rooms and services within hospitals today, there has been a general growth in support functions, corridors, and overall area. Some causes for this are need for infection control (separation of functions, more corridors), regulatoU demands, ADA barrier-free requixements, more equipment storage, more complex infrastructure demands, and the need for competitive patient and staff amenities. Academic teaching hospitals - at the forefront of all medical advances - are incorporating ever more medical equipment and research approaches (clinical trials, etc.) which demand more staff and specialized space. One measure of the growth in overall hospital space is the "net to gross" multiplier, a planning metric used to convert programmed "net" space into actual building size. These multipliers have been growing over the past 10-15 years. Whereas the gross area of a hospital used to be 60% to 70% greater than the net area, it is now well over 100% greater. Stanford’s space programs, for both SHC and LPCH, accurately reflect this change in the magnitude of space multipliers, comparable to other recently planned hospitals. Building Height Comparisons - Floor-to-Floor Heights Several factors lead to the need for greater "floor to floor" heights in each floor of a hospital. (This is the distance between the strucm~:al floor plates, not the visible ceilings.) These include CA seismic and structural codes, more complex infrastructure, ceiling booms for medical 11/7/2007 Peer Reviewer: Marlene j. Berkoff, FAL&Page 4 of 7 equipment and patient movement slings, and need for access for maintenance and change. Overall, floor-to-floor heights have increased by about 2’ over the past 15 years. Floor-to-Floor Height Comparisons of Hospitals The floor-to-floor heights proposed for Stanford’s hospital developments were compared to those of other recent CA and national hospital projects. The Stanford proposed heights are within the current norms. Nursing units are proposed to be 16’ high and Diagnostic and Treatment areas (Surge~, Imaging) to be 18’ - 20’ high. 2.Observations and Conclusions Design heights for floor-to-floor vertical space are reasonable and comparable to those used by other planners and institutions. Thus, even a 3-stoU above-grade building may well exceed 50’, the current height limit of the Palo Alto CiD" zoning code. D_-ospita! Configuration - ve_r, ical vs. horizontal balance - relative to overall bui!ding height Total building height depends on the way buildings are configured - how much is stacked up vertically and how much is spread out horizontally. Overall building height xvq.ll result from how the buildings are configured., how many stories high they are - not the height of each story. Maior site area limitations Current design proposals for SHC and LPCH are over 3 stories and over 50’ in height. SHC is proposed as 7 stories tall (120’ - 130’) and the LPCH addition as 4 stories (about 70’). The prelimmaW design concepts are based on contemporaU principles of good hospital planning, on the necessitT (particularly for LPCH) of coordinating functionally with e:dsting service locations, and on the critical importance for both institutions of keeping all existing medical services in operation during the phased construction of new space. The design configurations are also dictated by the 1Lmited site area available. Even a 3-stoU above grade hospital structure (which the SHC I-EMP is now) can bard? fit within the 50’ zoning height limit of the CiD~ of Palo Alto. Thus, regardless of good planning goals - if the v, vo hospitals were to construct the appro.’,:imate magnitude of space currently proposed in the space programs, and to maintain a design configuration profile of no more than 3 stories, they would occupy considerably more than double the amount of horizontal site area the proposed plans currently show. The e_~stmg Stanford Medical Center campus does not have enough area available to accon~’nodate a horizontal development of approximately 50’ in height at the magnitude of space required, plus required access, par-king and service, and some green open space - regardless of good functional design. Different Plan Configurations for SHC and LPCH The proposed plans for SHC and for LPCH differ from each other considerably. SHC is basically a replacement hospital proposed to be 7-stories above grade, with 5 floors of nursing units stacked on top of a 2-stoU base of diagnostic and treatment floors. LPCH would be a 4-stoU tall above-grade addition, with 4 floors of nexv nursing units horizontally adjacent to the e~sting building, connected by corridors and support spaces. 11/7/2007 Peer Reviewer: Marlene j. Berkof~ FAL’&Page 5 of 7 In both cases, the plan configurations and overall bnildmg heights result from and are in response to existing circumstances and limitations, including 1Lmited site area available in the right locations, necessitT for construction to be phased so that patient care and operations can be maintained throughout the development process, and the necessity to relate to eMstmg structures and site conditions. Factors to consider relative to the "stacked" configuration of the SHC replacement hospital Three options for the SHC were explored, but in all cases, the "base footprint" - the amount of horizontal site area used by the building - was essentially the same: about 170,000 BGSF. This is as big a footprint as can be fitted on the site, while s011 allowing space for a new par-king structure, ambulance access, and necessaU circulation - as well as space to stage and implement the construction project. In each option, different nursing unit configurations were created, but all needed to be stacked on top of the same "interventional platform" base to fit on the site. The number of stories did not vaU. This "stacked" configuration is common for most large hospitals of over 250-300 beds. There are a number of operational and patient care advantages, as well as efficiency of land use. Factors to consider relative to the Horizontal Configuration of the LPCH addition The proposed LPCH project is a side-by-side addition to the e~stmg hospital, with some renovation of e:dstmg space and considerable relocation of patient beds from e:dstmg space to new construction. There is no other way to add patient beds to this structure. 1Even if desired, additional stories can not be added on top of the e.xistmg building due to CA seismic code resmctions. Future Expansion and Change Concerns For both LPCH and SHC, the e:dstmgStanford site appears nearly "maxed out." This creates a s~ong need to maximize the use of the site in the most space-conservative way. The LPCH plan outlines space for one additional future nursing unit to be built, supported by and connected to the other services in the hospital. It is not clear how or if the new SHC could expand in the future - although there will be a little latitude after the new replacement hospital is completed and the oldest portion of the existing hospital is demolished. Comparative hospital configurations The configuration of a number of recent comparable hospital developments was reviewed, including UCSF at Mission Bay, UCI~,, E1 Cammo, Mass. General, Johns Hop -kins, and others. EveU single one of those hospitals is planned or constructed with a "stacked" configuration of nursing units on top of 1, 2 or 3 stories of a diagnostic and treatment base. Examples of appro:,ffmate heights of these recent developments range from about 90’ for E1 Camino Hospital (5 stories) to about 110’ for UCSF at Mission Bay (6 stories), about 120’ for Hoag Memorial (6-7 stories) about 140’ for UCI_~. (8 stories), and about 200’ or higher for Mass. General and Johns Hop-k_ins, at 10 and 12 stories respectively. Observations and Conclusions Given the site area restrictions as well as the need to maintain ongoing operations du~5_ng construction, the hospital design configurations proposed by Stanford make sense. It is difficult to imagine other realistic concepts fo~: providing the needed space and maintaining a sig-nificantly lower height profile for either of the buildings. There may be other variations 11/7/2007 Peer Reviewer: Marlene J. Berkof~ FALq Page 6 of 7 of these concepts, but it is highly unlikely that they would result in significantly lower profiles or alter the overall impact of the bmldmgs on the site. Services located off-site Stanford has akeady off-loaded all of the "non-essential" services allowed by CA code to be off site. These include accounting and business services, human resources and many administrative functions. This adds up to about 200,000 GSF of space that is off campus and is not intended to be brought back. None of these services is included in the current proposed space pro~ams. Staffing This report does not address staffing of the proposed hospitals. The EIR application states the staffing/personnel projections which Stanford has developed. These numbers relate to both the numbers of inpatient beds and also to all of the other outpatient and support services that comprise the hospital functions. The primaW increase in staffing is due to the increased numbers of patient beds. 1.Space as Proposed by Stanford The Peer Review overall assessment is that Stanford’s space programs and plans are not in any significant way outside standard norms for good planning and current-dW medical practice, especially for a premier academic teaching hospital that is being designed to serve at least 25-30 years into the future. The sig-mficant increase in size proposed for both hospitals is, unfortunately, ~,pica! of recent hospital improvements and development projects in CA and across the nadon. While perhaps 5 - 10% of space might be reduced without changing functions, this will not have a significant impact on the order of magnitude of the two projects. (Tt~s is about the ma:-dmum amount of ~’tightemng" that can possibly, occur during design, and even that is very difficult.) In the normal project development process, Stanford xvRl be trying to "tighten" its spaces any~vay in an effort to conserve site and minimize costs. They are akeady doing this with the LPCH space pro~am. Impact of Proposed Increase in Numbers of Beds If Stanford’s patient volume assumptions and bed number projections are reasonably accurate and acceptable - then the rest of the space follows in a rational fashion and compares reasonably well with sinai!at spaces for peer institutions. However, if the rationale for Stanford’s projected increase in new beds is not deemed. supportable, then the space needs could be reduced substantially. Stanford appears to have done solid "due diligence" in forecasting the number of additional patient care beds it needs for SHC and for LPCH. As far as this Peer Review investigation can tell, the additional patient bed need is valid. 11/7/2007 Peer Reviewer: BIarlene J. Berkoff, FALq Page 7 of 7 City of Pa!o Mto Peer Review of proposed Stanford University Hospita! Projects Stanford Hospita! and Clinics (SHC) - adult hospital ® Lucile Packard Chi!dren’s Hospital (LPCH) P._relJrm’nary Peer Review Report November 6, 2007 Presented below, organized by key issue, are factors, benchmark data, observations and comments relevant to areas of potential concern for the CitT of Palo Alto regarding both of Stanford’s facilities renewal and replacement projects. The Peer Reviexv investigations are aimed at determining to what extent Stanford’s proposals fall within the norms of current-day hospital planning and construction, identi~-ing areas where Stanford may be outside the norms, and analyzing the underlying rationales and impact of the proposed projects’ scope and variances from norms, where applicable. ao Bed Numbers - the fundamental "driveP’ of space needs Both of Stanford’s proposed projects are for inpatient hospital expansions and improvements. The number of inpatient beds is the most basic space driver, not only because the bed rooms themselves require space, but also because all the support services, from operating rooms to staff areas to food service and housekeeping, are calculated based on the number and types of patients being accommodated. 1. Bed Numbers - EMsting and Proposed Existing 456 Proposed 600 Ir~crease SHC LPCH 257 361 104 40% Total 713 96!248 35% % ~ncrease 32% Note 1: SHC is licensed for 613 beds, but only 456 are operational The rest were converted to other functions years ago. The proposed number of beds, 600, witl sti~ be fewer than the original bed license. Note 2: LPCH is in the process of building out the remainder of its current 257 beds, which were approved and are part of the ftrst phase of work. Note 3: The bed numbers are still slight_ly in flux - depending on final plan layouts. The order of magnitude is not intended to change in any sig-mficant way. Note 4: LPCH also contracts with Sequoia, Washington ~remont), and E1 Cammo Hospitals where it locates additional beds (approx. 40) and will continue to do so. Source of bed numbers Stanford has done significant research and analyses to determine the appropriate number of beds to provide for each hospital. The details of these studies form part of Stanford’s business plan, the details of which are confidential information. Stanford is currently documenting and providing the information that can be shared with the public. 11/7/2007 Peer Reviewer: Marlene J. Berkoff, F~a.~Page 1 of 26 The process Stanford used to develop their bed number projections is as follows: a. Stanford Strategic Business Development departments in each respective hospital analyzed relevant factors internally, from perspectives of service, operations, technology’, staffing, regional market, current-day and future healthcare modalities and trends, and financial soundness. b.Individual departments also examined patient volumes, health care trends, new technologies, etc., both internally and with the help of outside specialist consultants for their individual areas. c.The Strategic Business Development departments then engaged reputable outside specialist consultants to review their internal assumptions and data, and to develop bed number projections: i. Accenture analyzed the situation for SHC ii. Chartis Group did the same for LPCH d.Finally, the two space programming f~rms, KSA for SHC and SmithGroup for LPCH, also reviewed the bed projection numbers developed respectively by Accenture and Chartis. e. The final bed numbers result from a consensus of all of these efforts and analyses. Factors that influence bed number projections: The factors that impact the determination of the bed numbers are as follows: a. Demographics studies - indicating both an aging and a growing population i. A 2007 New CentuQ" Healthcare Institute report states that, in San Mateo and Santa Clara counties, "the number of people over age 65 will triple in the next 40 years" and that age group "will have four times the utilization of hospitals as people under 65." The report states that this will sig-nificantly affect demand for healthcare services by 2011. b.Disease D-pes and medical conditions: i. Longer lived population, more multi-system failures, medical problems of greater acuiD’, more inpatient hospitalizations and more critical care required ii.Increased frequency of different medical conditions - diabetes, bariatrics (obesity..) c.ALOS (average length of stay) has "flat-lined." It had been decreasing for some time, as patient were discharged from hospitals with shorter inpatient stays, or treated as outpatients, not inpatients. Decreasing )~LOS meant more beds xvere available for use. That situation has turned around now for the following reasons: i.Outpatient care has akeady siphoned off about all that can be done that way ii.Shorter inpatient stays have about reached the limit of discharge safe~" i~.An aging population means more elderly, frail and multi-system failure patients are now beginning to stay longer in the hospital. d.Stanford reports that both hospitals are turning patents away due to lack of beds to put them in. i. In fiscal 2005, LPCH turned away 200 patients ii. In fiscal 2005, SHC turned away 500 patients e.Increased focus on disaster preparedness and emergency response to potential mass disasters in the region i. Review of capacities of all hospitals in the region ii.Consideration of the fact that Stanford is a Level I Trauma Center serving several surrounding counties !1/7/2007 Peer Reviewer: M~lene J. Berkof~ FALA Page 2 of 26 Conclusion: a. Based on the information provided to date, it appears that the bed numbers proposed for the new hospitals seem reasonable and that thorough analyses have taken place at several levels. i. The increase of approximately 35% in bed numbers for hospitals that were planned over 25 years ago (SHC) and nearly 20 years ago (LPCH) does not seem out of line with what might be expected, given the time lapse, the changes in demographics, the increasingly renown expertise at both SHC and LPCH, and the need to look to the future. Private Patient Bed Rooms A major facto{ in the size of the new hospital additions and improvements is the fact that near!y all replacement and renovated patient bedrooms will be private, single rooms, each with t_bmir own toilet room. This is a significant change from the e.,dstmg situation and leads to the need for considerably more square footage. Comparative Patient Bed distribution SHC LPCH Totals Existing Beds Proposed Beds increase % of Beds in in PrivatePrivate Semi- Total Private Semi- Tota~ Privates Rooms 199 50 249 Private 257 207 464 456 257 713 512 345 857 Private 88 600 16 361 104 961 313 295 608 85% 96% 89% Bed Number Comparison \Vhereas the hospital planning proposes a total increase of 248 patient beds (SHC plus LPCH), in fact the increase in private rooms will be a total of 608 beds. That mea~as appro.,mnately 368 beds that are now located in semi-private patient rooms, with shared toilet/shower rooms, will be renovated to be in single patient rooms with individual toilet/shower rooms, in addition to the 248 new patient beds which will all be in singles. Industry Standard Almost all new hospitals across the nation ~e being planned for single patient, private bedrooms, with individual toilet/shower rooms. This research found no hospital or consultant who was planning for other than private rooms or had done so in recent years. The reasons for this are as follows: a.Reduction of hospital-acquired infections - a major industry-wide problem today b.Reduced likeiitmod of medication e~ors - also a major problem c.Reduction of patient transfers from room to room due to inabiliD~ to match i.Patient disease / level of acui~ / level of infectiousness ii.Patient gender / age d. Reduction of patient falls and nurse injuries resulting f~om patient transfers 11/7/2007 Peer Reviewer:_Marlene .l" Berko ff.. FAL&Page 3 of 26 Higher bed occupancy / improved space and staff utilization - eliminates necessity to leave some beds empty due to inappropriate mL~: of gender, age or disease Increase operational efficiency - improved bed utilization (no empD~ beds due to incompatible roommates.) Patient preference and satisfaction "2006 AIA Guidelines for Design and Construction of Health Care Facilities" Section 3.1.1.1 (1): "In new construction, the maximum number of beds per room shall be on_._~e unless the functional program demonstrates the necessity of a two-bed arrangement. Approval of a two-bed arrangement shall be obtained from the licensing authoriD~." Many states, including CA, base their state codes on the AL’a, Guidelines. Some states, including CA, are currently using older versions of the Guidelines, which do not recommend single rooms as the standard. Many states, including CA, are in the process of transition. The current status is as follows: a. According to the AL~, Guidelines authoritT in Washington, DC, 9 states have adopted the 2006 Guidelines in total, meaning they are now requiring single patient rooms in all new inpatient hospital faci~ties. i.Those states are: Georgia, Virgima, W. Virginia, Tenn., Kansas, N. Dakota, Louisiana, Arizona, and Montana. b.11 additional states are also using the 2006 Guidelines, but use them with amendments, so without reading all the individual state codes, it is not possible to tell if they have included or excluded the recommendation for all single rooms. ........... ~ a,~opnon 9 more (including CA) are already in the process of doing so. d.California is one of 24 states that writes its own code (including New York and Illinois); i.17 of these states, including CA, NY and IL, base thek codes on AI_A Guidelines; ii.The highly populous states of NY and IL are currently considering adopting the 2006 Guidelines iii. CA is akeady in the process of doing so.. e.Since CA xvrites its own code, it is impossible to state when or if they will ultimately adopt some or all of the Guidelines - and whether or not this will include the all- single-room recommendation and make it a requirement. i.This action is scheduled for decision sometime in 2{)08, but evidently this has been debated for some years and a decision still mW not actually occur in 2008. Hospital of the Future, Lessons for Inpatient Facility.- Planning and Strategy This document is a 2007 publication of the Health Care AdvisoU Board, a multidisciplinaU national organization comprised of numerous hospitals, architects, planners and construction experts across the nation. Hospital contributors include Johns Hop -~kins, Sutter Health, UC Davis Medical Center, UC Irvine, UCL~, Univ. of Michigan Health System and Kaiser Permanente. a.The report states that "Private Med-Surg Rooms (are) the New Baseline" and provide "Widely-Ac -knowledged Benefits." 11/7/2007 Peer Reviewer: N’[arlene J. Be~koff.. FAL&Page 4 of 26 o Discussions with colleagues and health care providers: SummaU of comments: a. Kaiser - single rooms are the current "industry standard" - being used in all Kaiser template hospital plans and designs b.Colleagues in national planning and architectural firms state they have planned and designed only single patient rooms in new hc~spital developments: i. Ellerbe Becket, HDR, KSA, SmithGroup, KMD, HOK, Fong & Chan A sampling of hospitals that have planned and/or recently constrwcted all new patient beds in private room (and converted most old doubles to privates);. a. In CA: UCLR, UCSF Mission Bay, .Santa Clara Valley Medical Center, CPMC, Kaiser, San Francisco General, PAMF San Carlos, Sutter Eden Medical Center b.Other locations: Ohio State, Universi~T of Florida-Shands, UniversiD, of Michigan, Duke, TriHealth Hospitals (Cincinnati). Problems and Issues with All Single-bedded Patient Rooms a. In some cases, it is not possible or feasible to renovate e.sstmg semi-private rooms into singles i.Structural barriers - walls that cannot be reasonably relocated ii.Operational barriers - too few beds on nursing unit would result if e.,dstmg doubles are converted to singles, ma -king nursing care costly and inefficient iii. Cost barriers - the institution simply cannot afford the construction costs When it is possible to convert e~stmg double rooms to singles, the resulting space is often not exactly what would be planned if starting from scratch. i. Emsting interior walls are often left in place - structure, infrastructure, and costs make relocation prol~ibitive ii. Resulting space may be slightly larger or differently" configured than ideal \~?~en new single patient rooms are added to a hospital, but some e:,:istmg rooms are left as semi-privates, a hospital is faced with °’two classes of care." i.Patients object - 2°~ class feeling- lowers satisfaction, public image ii.Lack of standardization can lead to increased medical errors iii.Undesirable situation - ~.~pically tolerated as an unavoidable transition step ix-.Current plans for both SHC & LPCH avoid this problem. All rooms will become private, except a veW few where this is not medically preferable. Costs i. Single patient rooms take more space than doubles on a per/patient basis, and each requires its own toilet room. This adds to construction cost. Staffing Nursing units with all single rooms are larger, use more space than the older semi- private room layouts. Corridors are longer and rooms more spread out. i. Typically staffed by a more decentralized nursing system - but not necessarily an increase in nursing staff. The ratio of nurses to patients can remain the same. ii. There may" be a marginal growth in support staff- more deliver.- personnel, more space for housekeeping to dean. 11/7/2007 Peer Reviewer: Marlene j. Berkoff, FAIA Page 5 of 26 Conclusion Given the pervasive attitude and exddence-based research favoring private patient rooms, it would be unreasonable to expect Stanford to plan for anytt~ng other than private patient rooms. a. Co The Health Care Advisory Board research assesses private patient rooms as having a strong positive health outcome benefit and a moderately positive cost benefit. The patient health outcome benefits include: i.Reduced rates of infection. ii.Reduced falls, injuries - to nurses, staff and patients iii.More rapid discharges - incorporation of family, improved healing environment Even though construction costs for additional area are larger, there are long-term operational cost savings as well as patient care benefits: i.Greater nursing efficiency with decentralized care system ii.Increased utilization of beds - no emptT beds due to incompatible roommates iii.Reduced time spent in transport -shifting patients from one room to another iv.Reduced risk (and incidence) of infections, patient falls, and nurse injuries from moving patients Size of Patient Bedrooms Single rooms require more space per patient than semi-private rooms, plus each single room requires its own toilet/shower room. Room size varies, but is ~pically viewed as consisting of three separate zones of activi~,, in addition to the toilet room, each with its own requirements: ~The patient care zone - patient bed area o The professional caregiver zone - the required space around the bed for physicians, nursing staff and medical equipment The family / care-giver zone - an increasingly" important component of patient care. Recent evidence-based design indicates faster patient recoveU with family involvement. Factors to consider in analyzing the space "programmed" or planned for patient bedrooms Understanding the plans and space proposed for patient bedrooms is veU important since patient rooms are significant repetitive elements throughout both hospitals, and account for a major part of the space in both the SHC and the LPCH projects. ~ LPCH:Inpatient nursing units = 49% of total hospital area ~ SHC:Inpatient nursing units = 50% of total hospital area Inpatient nursing units include all nursing support space, nurse stations, staff support, medication, satellite pharmacy, clinical offices and work stations, in addition to the actual patient bedrooms. All these support spaces are critical to the functioning of the nursing units and are D’pically sized in relation to the number and acuiQ- of patients in the unit. Data is presented in Net Square Feet (nsf) - the actual area inside the walls of the patient rooms. i. Toilet rooms are included in the areas presented, as is the circulation area within the room. Outside corridors are not included. Pediatric patient bedrooms are typically a little larger than adult bedrooms, primarily because one or even t-wo family members are often included in the daily patient care, including sleeping overnight in the patient room. 11/7/2{)07 Peer Reviewer: Marlene J. Berko-ff.. FAL&Page 6 of 26 Each nursing unit requires approximately 10% isolation rooms for patients with either highly infectious diseases, or patients who are themselves in a compromised situation and must be protected from airborne infection. Isolation rooms require ante-rooms and isolation alcoves in addition to the regular room space. This additional space has not been included in the space comparisons which folloxv, but it does add to overall area in each nursing unit. There are several different tTpes of patient rooms in each hospital, leach room ~pe has some special requirements and sizes vaU accordingly. i. Regular medical/surgical patient rooms (med/surg): These are the rooms used for the bed area comparisons with other hospitals. ii.Intermediate care - step-down units iii. Critical care, ICU’s for specials" services, Cardiovascular ICUs, Pediatric ICUs, NICUs (neonatal intensive care units), and Compromised Host units for immuno-suppressed patients. ix-. Stanford has a greater proportion of specialized and high acui~, rooms than a ~’pical communiD~ hospital. v. This research has not toed to compare the specialized t?~es of rooms with other hospitals. While not sig-nificantly larger than the typical med/surg rooms, they do have separate features, isolation alcoves, specialized airflow, and additional support areas which often occupy extra space or lead to different configurations. Space for patient bedrooms is "programmed" - that is, de£med in area -before actual plan layouts are developed. This programmed area is a space target. The actual room may not end up being exactly that size (could be smaller or larger), but it will be within a ve~ close range of the target number. The plan layout of patient rooms within the building affects the space used: i. Older hospitals typically designed "rn~ror una~e rooms - back to back padent rooms with beds and toilet rooms on alternate sides of the wall in eveU other room. This allowed for grouping plumbing fk~:tures and nesnn~ some spaces - creating a fairly tight space-efficient layout. ii.Recent outcomes research has found that "mirror image" layouts tend to increase medical errors. With medical gases and equipment hook-ups, for example, on alternate sides of the bed, nursing and medical staff may inadvertently reach for the wrong side in an emergency, leading to delays, confusion or occasional medical errors. iii.Current best pracdce is to design rooms (within a D~pe - medical/surgical beds, critical care beds, etc.) to be identical, %ame handed." No mirror images. Though this may take slighdy more space, increasing numbers of hospitals, especially those with very" high acuiD" padents like Stanford, are doing this. Academic medical centers ~equire larger patient rooms: i. Interns, residents, other trainees and attending faculty must often all be in the room with the patient at the same time - in addition to medical equipment. ii. Academic medical centers have the highest acuity- padents with complex medical conditions, requiring the most extensive array of equipment and tecl~_nology. This occupies more space in a patient bedroom than in a communiD~ hospital. 11/7/2007 Peer Reviewer: 5~arlene J. Berkoff, FAJ2~Page 7 of 26 2. Private Room Area Comparisons Net Square Feet - including toilet rooms 1 2 3 4 5 6 7 8 9 HC Firm Firm FirmSHCLPCH Advisory Kaiser Study UCLA UCSF #1 #2 #3Board High 300- 318-240- 325 340 290 Most common Not incl. toilet 220-230 Assume Toilet of 50 270- 28O Mean / Median Both not Incl. Toil. 250-268 Assume Toilet of 50 Not incl. toilet 300 Assume Toilet of 5O 300- 318 260- 300- 300-240- 350 280 310 350 300 260 Notes by Column Number: Note 1 : Note 2: Note 3: Note 4: Note 5: Note 6: Note 7: Note 8: Note 9: SHC private rooms tTpica.lly programmed at 300 nsf. Larger areas are for Isolation and Bar, attic Rooms, but do not include isolation alcoves/anterooms. LPCH private rooms programmed at 278 - 298 nsf, depending on room tTpe, plus an additional 40 (50 for ADA accessible) nsf for the toilet room. The Health Care AdvisoU Board 2007 report suggests an "optimum" range of 240 - 290 nsf including toilet room. They include both academic and cornmunitT hospitals in their data base. They did not distinguish between adult and pediatrics. The Kaiser Study, completed in 2005, combines data obtained from 13 national health care planning and architecture firms, based on the bed areas programmed for recent hospital developments in their practices. (Names upon request) The areas presented did not include toilet rooms - so an area of 50 nsf has been added to the Kaiser study numbers to make a more valid comparison. The hospitals data includes both academic and non-academic institutions. The data was presented in ranges of high and low, most common, and mean and medians. The higher numbers in the ranges shown above are for private pediatric rooms vs. adult rooms. The "high" number, 300 nsf without toilet, just happened to be the same for both. Ronald Reagan UCI_~a, Medical Center - just finished construction. 5!0 beds in single rooms, 14 in double rooms (only for pediatrics and psychiat_D-). Typical Med!Surg room is 220 nsf + 40 nsf toilet. May, not inchide circulation area within the room for access to toilet room. ICU rooms are larger, 280 nsf. UCSF M_ission Bay - planned for 260 nsf rooms + 45-50 nsf for toilets. Planned to make all toilet rooms handicapped accessible - a common practice these days. A national planning firm, with numbers entirely based on academic medical centers. A national architecture f~rm, with numbers representing both academic and community hospitals. Another national architecture £u:m, with numbers representing both academic and community" hospitals. 11/7/2007 Peer Reviewer: ~Iarlene J. Berkoff., FAL4 Page 8 of 26 Respondents did not distinguish betxveen adult and pediatric patient rooms. Most data is understood to be for adult med/surg rooms - which was what was requested. Observations and Conclusions: a. SHC: The space programmed for single patient rooms falls within, but nearer the high end of, the norms for other hospitals. b.LPCH: The space prograrrm~ed falls more towards the high end of comparable recent hospital developments, but not outside the range. i. Approximately 200 of the total proposed 361 LPCH beds are being converted from existing doubles to new singles. ii. The space for each of these rooms may be somewhat larger than ideally necessau, dictated by e~stmg construction and layouts that cannot reasonably be changed. c.Considering the impact of the size of the private patient rooms on the projects as a whole: i. Even if each patient room were reduced by perhaps 10% (approx. 30 nsf) - the overall impact on the total project size would only be about 2.5%. ii. This will not alter the order of magnitude of the projects or significantly reduce building config~ation or impact on the campus and the Cig of Palo Alto. d.As the projects are developed in detail, the architects will be striving to "tighten" the layout as much as possible, while still meeting the functional goals. i.Stanford has an incentive to keep the rooms from expanding beyond their necessaU functional sizes because additional space increases construction cost. e.From a Peer Review perspective, the spaces programmed for the patient rooms for both the SHC and the LPCH projects seem reasonable relative to current-day planning norms. i. At this early stage of planning - when no design has yet been developed - the numbers proposed are reasonable targets, though the LPCH private rooms might be "tightened" slightly. ii. The key space impact factor is the decision to plan for nearly 100% private rooms, not the size of the rooms. Operating Rooms (ORs) Another key dement influencing the size of hospitals today is the "Interventional Platform," the combination of se~’vices including Operating Rooms (and all surgical support services), Cardiac Catheterization, Interventional Radiology, Pre- and Post Admission Services, and all Anesthesia and RecoveU services. Growth in Size of Operating Room Suites - "Interventional Platforms" The size of operating rooms and associated support space has dramatically increased indust_tT-wide, and nation-wide, over the last decade. The OR is no longer viewed as a single room, but rather as the hub of a complex array of interventional diagnostic and t~eatment services. However, it is useful to compare the relative sizes of the ORs themselves - which the following table wi~ do. The increased size of the basic unit (the OR) is largely driven by the following factors: a. Explosive growth in new medical technologies, including intra-operative imaging, int~a-operative MRI, robotics, and many vet." new medical technologies with substantial space and infrastructure requirements. 11/7/2007 Peer Reviewer: Ma~lene J. Berkoff, FAIA Page 9 of 26 bo Requirements for separate control & equipment rooms, observation areas, and many kinds of support space. Increasing numbers of physicians, nurses and technicians who work in or adjacent to the surgical suite at the very same time - adding to both OR and support space. Higher acuity patients with multi-system problems that must be addressed during surgeries. Increased concern about infection transmittal, requiring rigorous separation of clean and soiled areas - as well as separation of staff, patient and material access points. OR Size Comparisons Note: When SHC was designed in the mid-1980s, ORs were planned at approx. 400 nsf. Type of Space 1 2 SHC LPCH 3 HC Advisory Board General IP OR 650 600 650 CV OR 650 700 Ortho OR Neuro OR Special ORs 700 Future 1000 600-750 600-700 800 4 Kaiser Research Study Most common High Mean Median 566 600 750 658 650 800 633 625 750 638 650 900 5 Kaiser Standard 650 650 6 UCLA 450- 600 600 Firm #1 650- 800 (for range of OR types) ~IP = Inpatient ~CV = Cardiovascular ~Ortho = Orthopedics ~Neuro =_ Neurosurgerv Notes: All ORs are supplemented by significant amounts of support space, including *Control rooms for computerized equipment ~Pump Rooms for Cardiovascular cases *Scrub areas, sterile supply areas, induction areas (where anesthesia is started), and equipment storage Post Anesthesia Recover?" Units PACU) space This comparison has looked at the actual space in the OR itself as a measure of comparability from one institunon to another. 11/7/2007 Peer Reviewer: Marlene J. Berkoff, F_A_L’K Page 10 of 26 Both SHC and LPCH are within norms for standard OR sizes and for CV OR sizes. The space programs for SHC and LPCH do not specie, different sizes for specific ~pes of other ORs with two exceptions: i. LPCH specifies 700 nsf (plus support space) for special MRI and Robotic rooms. ii. SHC specifies two OR spaces of !,000 nsf each for future as-yet un -known technologies, which would include support space for those rooms. Note that UCLa., the only hospital that shows ORs at less than 600 nsf, was actually planned over 5 years ago. Even in that short time, there have been significant advances in medical technology, robotics, and intra-operative imaging equipment. Number of ORs a.Stanford’s proposed OR numbers i. SHC will increase from 30 ORs to 40, including 3 additional standard ORs, 2 additional image-guided ORs, and 5 large ORs to accommodate future technologies. ii. LPCH will increase from 7 to 12, including only- 1 additional standard OR, 1 new robotic OR, and 3 ORs equipped x~ith MRI b.This research has not identified relevant rules of thumb for the number of ORs relative to the number of patients in the hospital. i. The number of ORs is related to a particular hospital’s t?lae of patients and "centers of excellence" - which may be more or less surgically related ii. Academic teaching hospitals are likely to perform more surgeries and more complex surgeries than a community, hospital. iii. Academic teaching hospitals are referral hospitals for the most challenging regional medical!surgical cases - often requiring more extensive procedures, longer times, and therefore, slower through-put in ORs c.The number of ORs needed for a given hospital is defined by analysis of patient volumes and utilization patterns, including length of time and t-?.2aes and complexiD, of cases, hours of operation, and OR turn-around thzne. i. Stanford has done these analyses (see Item A above) as part of their projections for overall project size and scope - similar to the studies to determine numbers of patient beds. ii. The resulting numbers form part of their confidential business plan, related to projected revenue flows and operational costs. Observations and Conclusions: a. No def’mitive comment can be made on the number of ORs being proposed. i. Stanford’s consulting firms state that a larger number of ORs could have been justified by a standard utilization analysis, but that Stanford has become veU efficient in utilization and has pared down the numbers of ORs to minimize space and cost demands. b.Both SHC and LPCH have proposed space sizes for the most advanced high-tech "kinds of Operating Rooms that appear to be within the norms of other recent hospital developments. i. The space allocated for "future technology-" ORs for SHC, at 1,000 nsf per OR, is slightly- larger than the norm - but it is hard to say whether or not there will be need in those spaces for additional control rooms, computer or medical equipment, or new robotics of some sort. 1!/7/2007 Peer !Keviewer: Marlene J. Berkoff, FAIA Page 11 of 26 The additional size increment of about 200 nsf for these 5 ORs (a total of 1,000 nsf) is not sign.ificant in the overall project - and may be ve~T sound planning for unknown future needs. Some specialized ORs in other hospitals are akeady consuming 800-900 nsf. Emergency Department (ED) Issues Note: The Emergency Department at Stanford Medical Center is shared by LPCH and SHC. The Stanford ED is a Level I Regional Trauma Center, desig-nated to provide the highest level of care for serious emergencies, traumas and extreme/mass disasters. Stanford’s Level I Trauma designation covers a multi-counD~ region, including the counties of Santa Clara, San Mateo (southern portion), Monterey, Santa Cruz and San Benito. 1. Key a. issues As noted by Stanford: i.Insufficient numbers and sizes of treatment bays ii.Extreme lack of support space iii.Inefficient operations, slow through-put, long delays and waiting times, caused by lack of space and support areas National trends i.Higher acuW patients - aging population, multiple medical problems ii.Incorporation into ED of imaging modalities (CT scan, MRI access) iii.Inclusion of satellite pharmacies iv.Immediate pro.xi~ tO Interventional services - ORs, etc. - not just for convenience, but for patient safeD’: It’s a life and death matter. v. Provision of family space - especially for pediatrics vi. Dedicated triage areas - for separating levels of emergency vii. More provision for decontamination - potential chemical threats viii. Privacy concerns - HIPPA regulations - "hard-sided" cubicles or exam rooms instead of curtained separations - leads to more space Lx. Modular rooms - for fle:dbility to treat different medical problems x. Surge capacity - for mass disasters xi. Point of contact ED registration, paperwork - space implications within ED Number of Treatment Rooms Stanford is proposing an increase in ED treatment rooms from 43 to 57, approxi_mately a 33°,,’0 increase - comparable to the increase in patient beds. However, as with the number of ORs, the number of ED treatment rooms cannot be evaluated without -knowing confidential business plan information such as anticipated padent volumes, padent mkx, types and acuities of medical problems anticipated, etc. As described under Item A (above), Stanford appears to have done "due diligence" on the determination of these numbers. Some additional background validation is currently being obtained from Stanford. It stands to reason that SHC and LPCH have no incentive to create more treatment spaces than deemed necessary. The number of inpatient nursing beds available in each hospital limits the number of people who can be seen in the ED, since a sig-mficant proportion of 11/7/2007 Peer Reviewer: E/[ariene J. Berkoff, F_A_~,~Page 12 of 26 ED patients will end up being admitted to an inpatient bed. If beds are not available, it is unwise to admit a serious emergency patient to the ED. Rather, they wi~ be diverted and sent elsewhere if possible. (This is currently happening due to lack of both ED treatment spaces and lack of available patient beds.) The hospitals are also 1Lmited by the number of ORs available for emergency surgeries - as well as all other modaliries, CT Scanners, etc. These services are interdependent - and relate to Stanford’s patient volume, patient mix and medical problem projections, all key ele’ments of their business plan. Treatment Room Space Comparisons All of the rooms proposed for the new hospital development are private exam rooms, not open curtained multi-patient treatment bays. HC Room Description SHC Advisory Kaiser Study Board Most Mean / High common Median General Treatment Room Trauma Room 140 400 130-150 250 137 368 130 320 180 600 Fo Observations and Conclusions a. The General Treatment Room size is widen the norms for other comparable hospitals. b.The Trauma Rooms are larger than some comparable institutions. i.Each Trauma Room at Stanford is designed to be able to serve 2 patients in the event of multiple emergencies or a disaster - making the size very reasonable. Imaging Department Growth and Change There are huge variations in the t)qpes of spaces (rooms for CT vs. MRI vs. PET vs Rad. Therapy vs. Computer Equipment,, etc. etc.) that comprise a current-day Imaging Department. My investigations show that Stanford’s spaces (room by room) are comparable to others, when there are some directly comparable data. A detailed room-by-room chart would not reveal any variations from common hospital norms. Therefore, the following corm-nents have focused on the qualitative issues. Technology explosion Of all the departments in a hospital, the Imaging Dept. has experienced the most extreme growth and change in equipment, technologies, nexv approaches and methodologies. a. Interventional radiolo~- - This is something that barely existed 10 years ago, and was often subsumed within other departments. It has now become a major space occupier on its own, both as part of a vasdy expanded Imaging Dept. and as an adjunct to Surgery, Oncology, Cardiology and other subspecialties. 11/7/2007 Peer Reviewer: B.iarlene J. Berkoff., FALq Page 13 of 26 i.New, often heavy, equipment requires special mounting, often requiring more infrastructure and space than older buildings provide ii.Such equipment also requires separate computer rooms and other support spaces iii.Examples are advanced Cardiac Catheterization and Peripheral Angiography rooms which are larger and more sophisticated than earlier versions. Diagnostic imag-mg - especially for cancer screening and treatment - is another area experiencing massNe growth in terms of new technologies and applications i.Nexv computer-aided detection tools ii.Radiation therapy and simulation iii.Special interv’entional procedures - gamma -knives, stereotactic radiosurgeu, etc. Molecular imaging with special equipment is used in increasingly frequent genetic screening and analyses Myriad other new or improved technologies are now used much more frequently and overlap in their service from one dept. to another - sometimes requiring duplicate pieces of equipment to provide access for patients where needed. (CT Scan, MRI, PET Scan, EP ~lect_rophoresis), etc.) i. In a large hospital like Stanford, eveuthing simply cannot physically be near everything else, so some duplication is mandatory. ii. Patient saferT and operational efficiency may depend on appropriately accessible equipment. iii. It often costs less in the long run to duplicate some equipment in widely separated departments - which leads to more space and more equipment costs, but is balanced by better patient care, fewer negative medical incidents, and increased operational efficiency for staff (less travel, less transport, etc.) Digital imaging record keeping, transmittal and sharing across disciplines (and betaveen inpatient and outpatient settings) is adding a new dimension to space and technician needs in Imaging areas. i. Computerized PACS systems for recording, transmitting and archiving images ii. Need for technician work areas - vastly different from the old "fRm" days Blurred boundaries between Imaging, Surgeu, Oncology, Genetic Testing, etc. a. Newer techniques, equipment and medical advances have so blurred the distinction between Imaging and other specialties that it is no longer possible to do an "apples to apples" comparison at a department level i.A great deal of new imaging equipment is used in the OR setting ii.Other imaging equipment is used at the patient bed-side (mobile units which minimization is maki_ng ever more possible) - but adds to space needs on nursing units iii.Still other equipment is located witt~n special departments - Oncology, Emergency, \’~omen’s Centers, etc. Constant new developments dictate need for space to allow for expansion and change, and infrastructure to support it a. Imaging is one of the most expensive areas in a hospital - to build, renovate or move b. It is veU difficult to add new equipment o~ replace e~stmg because of demanding installation and infrastructure requirements i.Must be located where there is access for installing new and removing old equipment - which can be large, cumbersome and veU costly 11/7/2007 Peer Reviewer: ~’vlarlene j. Beckoff, FAL,’~Page 14 of 26 ii.Mounting- equipment often mounted on ceiling booms, heaw, must meet seismic codes, demands special structures iii. Special floors - wiring~ shielding, cabling, special load-bearing capacities iv. Special hook-ups -- power redundancies, cabling systems, xviring access v. Special shielding - lead lined wails, concrete bunkers vi. Additional ventilation requirements - heat, infection control Obserrations and Conclusions: a. The explosion of technologies and applications of imaging equipment and capabilities is creating a whole nexv set of space and infrastructure needs t’or hospitals nation-wide that didn’t e:,:ist when SHC and LPCH were planned. b.The veU uncertainly of new advances dictates that new hospital construction should be prepared to accommodate unexpected new developments. c.Especially in a research-based, academic medical teaching center like Stanford, being able to accommodate and test new developments in this field is critical to both top- notch patient care and to medical advancement nationally. i. The huge benefits of imaging technologies, which are often non-invasive, for both medical diagnoses and t~eatment cannot be understated. ii.In developing the space programs for SHC and LPCH, the planning ~-~rms worked closely with top medical professionals at Stanford to outline space appropriate for current and potential future equipment and procedures. iii. The new spaces being proposed are greater than in the existing hospitals - but cannot readily be compared as the newer technologies are distributed throughout the institutions, not grouped (as in the past) in one "Imaging Dept." Many spaces are designed to accommodate equipment that didn’t exist 10-15 years ago. ix,. On a room-by-room basis, specific rooms for specific pieces of equipment appear to be witl~n D’pical norms for new hospital developments. Overall Hospital Space G~owth and Hospital Size: Additional Factors to Consider In addition to the increase in space needs for specific rooms or services wittfin hospitals today, there has been a general growth in support functions, corridors, and overall area. Reasons for overall space growth: a. Infection control - and related patient safe~; i. Need to minimize cross-traffic - leads to more separate corridors b.RegulatoU compliance - more pape~vork, more workstations, more computers, more separation of clean and soiled work areas and disposal of trash and wastes c.ADA (Americans with Disability Act) requirements - add area to new- developments d.Decentralization of care - more space in and around nursing units, computer records, charting, medications, supplies, etc. e.Patient care team approach - multi-disciplmaU consultations and care planning require more support space, conference space, for physicians, staff and families f. Much more equipment throughout the hospital i.Nursing units - much equipment now used at the bed-side - needs storage space ii.Interv-entional diagnostic and treatment areas - extremely equipment intensive g.Space for change - access and flembility to replace or add equipment or renovate areas generates need for some "soft" space around highly intensive functiona! areas. 11/7/2007 Peer Reviewer: ~v~artene J. Berkof< FALA Page 15 of 26 Amenities i. Patients - market competitive, want pleasant waiting spaces, private bedrooms, family areas - research shows this improves patient outcome, speeds healing and hastens discharge, an ultimate cost saving and care outcome benefit. ii.Staff- major nursing and technician shortage - need staff lounges, lockers, food sen, ice, support areas to maintain competitive position relative to attracting and keeping key nursing and technical staff. iii. Visitors - families - now recognized as an important part of the patient care and healing process - need to be accommodated in the hospital plan. Academic Teaching Hospital - Special Requirements a. QuaternaU care provided - highest care level available nationally i.Greater acuit-y and severi~- than "tertiau" care of most major hospitals ii.Academic teaching hospitals are "hospitals’ hospitals" - as UCL~ noted b.Higher proportion of critical care rooms which take more space, more support and more equipment i. ICUs (CV ICUs, Medical ICUs, Pediatric ICUs, NICUs) c.Teaching functions - interns, residents, fellows - all see patients simultaneously during "grand rounds" and at other important times in patient care i.Require space for their pape~vork, study, etc. in addition to the space they take within ta:eatment areas. d. Greater amounts of newest equipment and technologies - for highest acuitT patients i.Academic medical centers are the inventors and testers of new clinical and medical equipment and procedures e.SmithGroup estimates a space premium of 10% - 15% for an academic reacting hospital vs. a community hospital. Multipliers: Net square feet (NSFB converted to departmental gross square feet ODGSF) converted to building gross square feet (-BGSF) A space program defines space requirements in terms of NSF - the actual space needed for each room throughout the hospital. However, buildings include many more spaces - corridors, public areas, mechanical rooms, etc. For architectural planning, space is defined in three categories, and multipliers are used to estimate the increase in space from one categoU to the next. NSF = the actual space inside the walls of each individual room. Space programs are developed based on NSF. DGSF = Departmental Gross Square Feet = the block of space that defines the cluster of seta~ices that accommodate a given function, like a nursing unit. DGSF includes all internal department corridors, internal wall thick_nesses, electrica! closets, shaft spaces, etc. - everything that makes up that "block" of space. i. DGSF multipliers vary by type of serrice. Large storage areas require few internal comdors or dividing walls, whereas nursing units require many. ii. DGSF multipliers range from a low of 1.3 x NSF to as high as 1.65 x NSF. 2007 Pee~ Reviewer: N’[a~lene J. Be~Fzoff, FAI~&Page 16 o f 26 Co BGSF = Building Gross Square Feet = the overall area of the entire building that must be built to accommodate all the NSF functions. BGSF includes all DGSF plus building service spaces like elevators and stairs, public toilet rooms, public circulation corridors and entries, all infrastructure space and all mechanical, electrical, boiler room and other support space that is not attributable to any one department, ~ building structure and exterior wall thic -knesses. i. BGSF multipliers are in the range of 1.35 to 1.4 x DGSF. Multipliers are used to estimate the size of DGSF blocks of space, and the overall BGSF size of buildings prior to the building being actually designed. Multipliers are based on empirical exqdence and data collected from the actual implementation of numerous project developments over many years. Multipliers have gotten much larger in recent years due to: i. Increased infrastt’ucture demands -information technology, communications closets, wiring / cabling access, etc. ii.Increased airflow and ventilation requirements, related to infection control and air quality management - bigger mechanical spaces, for example iii. Increased structural requirements in CA - more space for structure required iv. Increased need to limit cross-traffic for infection control purposes as well as patient privacy - leads to more separate corridors, more space, ttigher multipliers v. Increased space required for equipment incorporation and storage Multipliers used to be considerably lower. i. NSF to DGSF multipliers always varied, depending on the department, but nu~:sing units used to be more like 1.4, rather than 1.55 to 1.6 x NSF. ii.DGSF to BGSF multipliers used to range from about 1.2 - 1.25, rather tlian current higher numbers of 1.3 - 1.4. Multipliers have an enormous impact on the total space estimates. Cunrendy, they lead to building space more than double the size of the NSF areas planned. i. Multipliers are valid and applicable only as planning tools. ii. Actual design layouts are "the proof of the pudding," the actual implementation of fitting the programmed NSF flmctions into a building envelope. ,/7/2007 Peer Reviewer: ~,fa~lene J. Berkoff, FAL:i Page !7 of 26 Comparative Multipliers 1 2 3 4 5 6 Nat’l CPMC, Type of Space SHC LPCH Planning Kaiser UCLA UCSF, Firm SCVMC NSF to DGSF Nursing Units lnterventional/ Surgeries / Imaging Administration 1.60 1.65 1.65 1.30 1.55 1.60 1.55 1.35 1.6-1.65 1.3-1.35 DGSF to BGSF 1.35 1.40 1.3-1.35 1.40 1.35-1.4 Approx.Approx. NSF to BGSF 2.16 2.17 1.95--2.2 2.00 1.9-2.3 The NSF to DGSF multipliers presented in columns 1 and 2 represent a sampling of multipliers used in the SHC and LPCH planning documents. The DGSF to BGSF multipliers are used across the board for SHC and LPCH, respectively. \’4~ile there is a small variance in the multipliers used by the ~,o separate £~rms who did r_he programming for the two hospitals (KSA for SHC, SmithGroup for LPCH) - the end result is virtually identica!: For both SHC and LPCH, more than 2 x the NSF area is requked to accommodate the necessaU functions. These numbers are within the range used by a national planning £trm for 4 other recent academic medical center developments: o MUSC o Ohio State o UniversiD" of Florida-Shands o UniversitT. of Michigan a These numbers are well within the range used by a major fm~n for planning for CPMC, UCSF and SCVMC (Santa Clara Valley Medical Center) Kaiser informally reports that an overall multiplier (NSF to BGSF) of appro."d_mately 2.0 is wpical for hospitals these days. o Academic medical centers require more space than community.,- hospitals - teaching staff, residents and interns, incm-poration of research, more equipment, higher acui~- patients, etc. o Kaiser does not provide academic medical centers, only community- hospitals. 11/7/2007 Pee~ Reviewer: Marlene J. Berkoff, FAL.’a.Page 18 of 26 Building 1-1eight Comparisons - Floor-to-Floor Heights 3, number of factors lead to the need for greater "floor to floor" heights in each floor of a hospital (This is the distance between the structural floor plates, not the visible ceilings.) Key Factors driving potential Building Floor-to-Floor Heights a. CA seismic / structural codes require heavier-duty building structures i. Deeper beams require more vertical space b. More (and more complex) medical equipment creates a need for more vertical space for equipment mounting and stabJ~zation i. Functional requirements for equipment - imaging, etc. - needs both mounting area above the visible ceiling, and considerable vertical space in the patient-occupied zone ii. MandatoU requirements for stable mountings require sct’uctural bracing c. New -kinds of equipment require ceiling-mounted booms to operate i. Patient "slings" for moving patients - driven by need to reduce patient falls and nurse injuries (both increasingly serious problems) as wen as by bariatrics (obese patients) ii. Proliferating i~=agmg equipment which is often ceiling-mounted. d. Complex equipment and infrastructure systems create a need for ceiling access (maintenance, equipment changes) without disrupting functions below ceiling space i.Maintenance personnel need to be able to get into ceiling space and xvork, without opening up the ceiling from beloxv. e.Overall, in CA, new structural requirements, combined with medical and equipment demands, are adding approximately 2’ to older floor-to-floor heights. Building Floor-to-Floor Height Comparisons a. The proposed building floor-to-floor heights for the Stanford hospitals only apply to new consLguction. i. At SHC, the bulk of the hospital replacement xxd.ll be in a separate nexv building where these new floor heights will apply. ii. At LPCH, some floor heights will be compromised to match e~stmg construction and to avoid ramps between building sections, as necessaU - so they may not all be as high as the proposed numbers indicate. New floors without connections to e~stmg structure will be as noted below. b.Building floor-to-floor heights proposed by Stanford are veU prelimmau, since the bmldmgs have not yet been desig~ned. c.Right now, the height estimates are towards the top of the range for current-day design - but may well be slightly reduced as detailed design and engineering systems are developed. ! i/7/2007 Peer Reviewer: Marlene J. Berkoff, FAIA Page 19 of 26 Building Floor-to-Floor Height Comparison Chart Function Nursing Units Diagnostic & Treatment Areas (Surgery, Imaging) SHC & LPCH 16’ 18’-20’ Nat’l Planning Firm 1#-16’ 16’-18’ Kaiser 15’-6" 18’-19’ Firm #1 14’ min. 16’ min. Firm #2 16’ min. 18’ min. UCLA 15’-9" 20’ - 21" UCSF 16’ 18’ Observations and Conclusions a. Design heights for floor-to-floor vertical space are within the norms relative to other planners and institutions. b.Final floor-to-floor heights will be determined as design and infrastructure/ engineering systems are def’med. c.Extra vertical building height on a per floor basis adds considerably to the cost of a building - so there is a strong dis-incentive to add additional vertical height per floor if it is not deemed really necessaU to meet code, infrastructure and equipment needs. d.SHC is currently proposed to be 7 stories above grade, or a maxJ_mum of 130’ tall. i. Over that height, a reduction of approx. 1’ per floor would affect the overall building height by only about 7’. A floor height reduction of more than about 1’ is highly unlikely, given the ranges of contempora~ construction noted above. ii.If the 7-stoU building configuration is maintained as currently proposed, reducing the floor-to-floor heights on a per floor basis will not significantly affect the visual impact of the hospital buildings on the site. e.LPCH is proposed to be 4 stories above grade, for a total height of approximately 70’. i.The same comment applies - per floor reduction of height will have almost no discernable visual impact. f.In both hospitals, not all of the structure will be the max_imum number of stories tall. i. Both designs are proposed to step down to lower heights in various places. Hospital Configuration - vertica! vs. horizontal balance - relative to overall building height Total building height will depend on the way in which the buildings are configured - how much is stacked up vertically and hoxv much is spread out horizontally. Given that the floor-to- floor heights will not vaU much from the numbers noted above, height differentials will be the result of how the overall bu~dmgs are configuzed., how many stories high they a~e - not the height of each stoQ’. 11/7/2007 Peer Reviewer: Marlene j. Berkoff, FA~-k Page. 20 of 26 Major site area limitations a. Current design proposals for SHC and LPCH are over 3 stories and over 50’ in height i. As set forth in the Facilities Renewal and Replacement Project Application dated August 2007, Stanford currently proposes a design concept for SHC that would be 7 stories tall above grade (about 120’ - !30’) and for LPCH of 4 stories tall above grade (about 70’). ii. These preliminary design concepts.are based on contemporary,, principles of good hospital planning and design, on the necessity (particularly for LPCH) of coordinating functionally with e~stmg service locations, and on the critical importance for both institutions of keeping all e:dsting medical services in operation during the phased consmaction of new space. iii. The design configurations are also dictated by the limited site area available. Even a 3-story hospital structure above grade (which the SHC HMP is now) can barely fit with_m the 50’ zoning height limit of the City" of Palo Alto. i. Current-day floor-to-floor heights easily push a 3-stoU building over 50’. ii. The last SHC HMP bmldmg literally dug down a level below grade and scooped out the earth to create a below-grade floor with outside exposure, to meet codes and accommodate needed patient rooms. It was impossible at that time, without violating the 50’ CitT height limit, to fit in the needed number of beds any other way. Functional relationships and operational efficiency in the HPM project were compromised as a result. Hospitals are mandated by State code to provide operabte windows for all patient rooms, and no patient window can be less than 40’ away from another window. i. This dictates a spread-out configuration - which takes more space than t_he same square footage assembled into a tight block. Thus, regardless of good planning goals - if the two hospitals were to construct the approximate mag-mtude of space they deem necessa~,.-, as set forth in their detailed space programs, and to maintain a design configuration profile of no more than 3 stories or less, they would occupy considerably more than double the amount of horizontal site area the plans currently show. i. Two stories of diagnostic-~*pe space would require 36’ to 40’ of height, and one nursing floor on top would add 16’ more - totaling 52’ to 56’. The e:dstmg Stanford site simply does not have enough area available. i. Visual assessment of the site plan indicates that it would be impossible to fit the hospitals onto the site at all, while maintaining e:dstmg medical operations, if the buildings are configured horizontally- and do not exceed 50’ in height - let alone that they could be configured in a functionally- workable design. ii. There would be no space, or completely inadequate space, left for necessaU parking, serv-ice drives and access, deliveU zones, ambulance access, etc. iii. There would also be little or no open, green space left. 11/7/2007 Pee~ Reviewer: Marlene j. Be~kof~ FAL&Page 21 of 26 Different Plan Configurations for SHC and LPCH The proposed plans for SHC and for LPCH differ from each other considerably. a. SHC i~ basically a replacement hospital which is proposed to be a 7-story structure above grade, with 5 floors of nursing units stacked on top of a 2-story base of diagnostic and treatment floors. b.The LPCH project is a 4-stoU tal! above-grade addition, with blocks of nexv nursing units horizontally adjacent to the e~stmg building, connected by corridors and support spaces. c.In both cases, the plan configurations and overall building heights result from and are in response to ex_istmg circumstances and limitations: i. Limited site area available in the right locations to allow space needs to be met and to allow services to function and interrelate properly. ii.Necessi~" for construction to be phased so that patient care and operations can be maintained throughout the development process. iii. Necessity to relate to e.~sting structures and site conditions - juxtaposition of services, access points, service and deliveU pathways, and, in the case of LPCH, direct connection to emstmg building. Factors to consider relative to the "stacked" configuration of the SHC replacement hospital As noted, SHC will be almost totally a new 7-stoU replacement hospital. After the new hospital is built, the oldest portions of the existing hospital will be demolished, and the 3- story,. HMP section, bt~t in the 1980s, will be renovated for use for a number of support and administrative services, for ambulatoU clinic space, for faculty" offices, and possibly for other support or outpatient types of uses. Note also that some of the existing HMP nursing units will be renovated to accommodate patient beds serving LPCH. a. The SHC replacement hospital, totaling about 1.1 million building gross square feet, will have 7 occupied stories above grade, ma -king it about 120’ tall, with an additional +/- 10’ in height for mechanical and roof equipment. i.Three options were explored - and all three using variations of this concept. ii.In all cases, the "base footprint" - the amount of horizontal site area used by the building- was essentially the same: approximately 170,000 BGSF. iii. That appears to be about as big a footprint as could be fitted on the site, while still allowing space for a new par-king structure, ambulance access, and necessary circulation - as well as space to stage and implement the construction project. iv. In each option, different nursing unit configurations were created, but all needed to be stacked on top of the same "interventional platform" base to fit on the site. The number of stories did not vaU. This "stacked" configuration is common for most large hospitals of over _~0-o00 beds. There are a number of operational and patient care advantages. i. Greater speed, efficiency and safety in patient care using dkect vertical transport - between Emergency, Surgeu, Imaging and patient bedzooms, including ICUs and critical care ii.Shorter travel times and distances - more staff satisfaction and greater patient safe~- during transport (minimizes fails, bumps, jostling of I :s, etc.) iii. Dedicated elevator banks minimize cross-traffic between patients, the public, service deliveries and housekeeping/waste disposal systems while taking up less space than separated horizontal corridors. 11/7/2007 Peer Reviewer: ~’vi~lene J. Berkoff, F_,’a.LA Page 22 of 26 iv. MLrmnizes patient exposure to outside infection from any of these sources. v. Places the heaviest traffic areas (comings and goings) on the lower floors where access is easiest, and puts less frequently accessed areas (nursing units) on upper floors. (More people access diagnostic / treatment areas on a regular basis than nursing units.) vi. Enhances bnildmg securitT - fewer outside access points to manage and control, especially at night. Factors to consider relative to the Horizontal Configuration of the LPCH addition The proposed LPCH project is essentially an addition to the existing hospital, with some renovation of e~stmg space and considerable relocation of patient beds from e~stmg space to new construction. a. The existing LPCH hospital is 3 stories tall and is within the City’s 50’ height limit. Existing patient nursing units are primarily on the 3~d and 2’~d floors of this structure. b.The LPCH plan is to convert many of these to specialized critical care units, and to build a 4-stoU block of nexv patient nursing units adjacent to the existing hospital. c.Thus, the LPCH will be a largely horizontal expansion, rather than a vertical one - but it still requires a 4-stoU block of nexv space to accommodate the needed space. i. Note that is was not possible to add additional stories on top of the existing LPCH. Seismic codes have become more stringent since the building was first built, in the 1990s. Also, bnildmg on top of the patient rooms on the e.xistmg 3~a floor would have been extremely disruptive, if it were even possible. This is almost always true in CA. d. The horizontal addition has several advantages. i. It allows the new building to be structured in the most efficient way to accommodate the new design for all-private patient rooms. ii. Above the 1~ floor, the floor-to-floor heights of the new addition can meet current-day standards, and will not be restricted by the slightly lower floor heights of the exis6ng building. i~. The new bnildmg can meet all applicable codes, xvith no need for renovating older areas. iv. The new addition can incorporate space for a future additional wing adjacent to the new building. v. A new ground level (basement) wi~ be gamed, prox~idmg space for new support services and some new diagnostic/treatment services. e.There are also some unavoidable disadvantages to this -ldnd of addition: i. Separate elevator banks will have to be developed to se~e the new patient towers - so direct travel be~veen the 2~d and 3’a floors of the new area and the 2’~a and 3~a floors of the e~stmg building will not be possible. The only intersecting levels will be at the ground and 1~ floors. ii.Functions that serve all nursing beds, such as food service, cannot be duplicated under both sections of the hospital, so there will of necessity be a fair amount of horizontal travel and cross-traffic in delivering food to both the new nursing beds in the new addition, and the existing ones maintained in the older hospital area. The same will be true for all material deliveries, housekeeping, etc. 11/7/2007 Peer Reviewer: Marlene j. Berkoff, FALq Page 23 of 26 Future Expansion and Change Concerns Any hospital construction needs to consider the potential for future expansion and/or change. On the Stanford site, there is veU limited space for future growth, although some options have been suggested. Renovations to some degree are always possible. a. The LPCH plan outlines space for one additional future nursing unit to be built and still supported by and connected to the other services in the hospital. It is not clear hoxv or if the main SHC could expand in the future - although there wi~ be a litde tadtude after the new replacement hospital is completed and the oldest portion of the e:dsting hospital is demolished. i.Most of that space will be used by the medical school and its research functions. ii.A major new imtiative for academic medical centers nation-wide, advocated by the National Institute of Health (NIH), is "translational research" - a system of interconnecting medical research xv-ith clinical trial areas, to better promote the development and testing of new health care methodologies, treatments, and equipment. iii. The close physical relationship of the School of Medicine and its research components to both hospitals is a strong benefit for SHC and the LPCH. For both LPCH and SHC, the e~sting Stanford site appears close to being "maxed out." This creates a strong need to maxLmize the use of the site in the most space- conservative way possible. i. Major external building additions, with the exception of one more patient bed wing for LPCH, do not appear likely, or possible. ii.Given the continual changes in seismic codes in CA, it is highly unl~ely that any future vertical expansion could occur on top of the buildings now being proposed for either SHC or LPCH. This makes it all d~e more critical to build as much vertical structure as is reasonable at the outset and preserve as much horizontal area for future expansion or change as reasonably possible iii. This also adds a strong incentive to plan the most flexible concepts and layouts to accommodate internal change and renovations. Comparative hospital configurations Note that every- single one of the following hospitals is configured with nursing units stacked on top of 1, 2 or 3 stories of diagnostic, treatment, administrative and/or outpatient functions. UCSF at Mission Bay - being planned now (2007) i. 289 beds, currendy planned for a 6 story." building, 3 floors of nursing units stacked on top of 3 stories of diagnostic, treatment and support space. ii. They have to utilize a 3-stoU "base" since the ground conditions at Mission Bay prohibit building a deep basement. Many support functions (stores, food serv’ice, etc.) that are often located below grade cannot be so located at Mission Bay UCL5 - opening 2007-2008 i. 589 beds and 1.1 million bgsf, 8 stories tall above grade - 2 below grade - for a total of 10 stories. ii. The lowest basement level is for parking. iii. The f~rst basement level is for support space. iv. There are 3 levels above grade of diagnostic and t~eat_ment functions. 1/7/2007 Peer Reviewer: MarleneJ. Berkoff, FAI~A Page 24 of 26 v.There are 5 stories of nursing units stacked on top of that 3-stoU above-grade base. c.Johns Hop-k_ms - opened 2006 "~9i.0_0 beds in a Cardiovascular and Critical Care Tower, 12 stories ii.205 beds in a Children’s Tower, 12 stories iii.Total of approx. 1.5 million square feet - plus outpatient clinical space d.Massachusetts General Hospital - being planned now (2007) i.An addition of 150 beds plus much diagnostic and treatment space ii.150 beds iii.10 stories e.Hoag Memorial Hospital, Heart Vascular Institute - Nexvport Beach, CA, 2007 i.96 bed addition ii.375,000 gross square feet iii.6-7 stories f.E1 Cammo Hospital, Mountain View, CA i.426 beds - addition being planned now (2007) ii.5 stories - 1 level partially below grade (4 ~/;_ stories above grade) iii.450,000 gross square feet ix-.Lower 2 levels diagnostic, treatment and admmisra:ative functions v.Upper floors, nursing units g.St. Joseph’s Hospital and Medical Center, Marrow Neurological Institute, PhoenLx, AZ - 2006=2007? i.475,000 gross square feet ii.144 beds iii.6 stories Serv-ices !ocated off-site 1. Stanford has akeady off-loaded all of their "non-essential" services. 9 These include all services that are, by CA code, not deemed essential to the operation of a hospital in its main facility. That is, they can be located elsewhere. These include, but are not limited to: a.Many admimstrative and office functions b.Data processing, financial and business office functions c.Warehousing and bulk storage None of those seta;ices are planned to be moved back to campus There are no other services that Stanford can move off-campus - all remaining services included in the space programs are deemed "essential" by code as well as functional necessity. Staffing This report is not dealing dkec0y with staffing of the proposed hospitals. The EIR application states the staffing / personnel projections which Stanford has developed. These numbers relate to both the numbers of inpatient beds and also to all of the other outpatient and support services that form the hospitals. The following comments are general observations only: Additional staffing for additional patient beds a. An increase of 240 patient beds on site will necessar~y lead to an increase in nursing staff, in ratios mandated by CA State code. b.There will also be a marginal increase in support staff related to the additional amount of area to be occupied by the additional beds: 11/7/2007 Peer Reviewe~: Marlene j. Berkoff, FzA_Iz-\Page 25 of 26 go i.Housecleaning ii.Food Serv-ice iii.Deliveries A comparable increase in staff may not be required for the ED or OR areas a. Stanford is wor -king in constrained circumstances now - with long delays and back- ups in the ED, for example. i.More space may simply spread out the staffing, and relieve patient xvaiting and back-up - not necessarily leading to more staff. Service and Maintenance personnel a.Some additional staff will be required for maintenance, housekeeping and deliveries due to the greater physical area to be serviced. Issues to consider relative to staffing: a. Peak shift 6_rues - which will most likely be at around 7 am and 3 pro, when the hospitals are most active and when nursing shifts change and there is a temporaU overlap in personnel. i. This primarily mapacts par-king and ~affic b. Total employee / staff increases: i.Distribution of D-pes of employees - probably mostly at mid or lower levels of the professional and economic scale. Needs to be defined by Stanford. c.Impact on housing versus par-king and traffic i. Housing impact related to both overall absolute numbers of additional employees and to their income distribution ii.Traffic and par-king related to shift times and hours .of operation of many services, especially nursing st~fts and outpatient hours. Summa~ 1. Spaces a. as Proposed by Stanford The Peer Review overall assessment is that Stanford’s plans are not in any significant way outside standard norms for good planning and current-day medical practice, especially for a premier academic teaching hospital that is being designed to serve at least 25-30 years into the future. While perhaps 5 - 10% of space might be reduced without changing functions, this will not have a significant impact on the order of magmtude of the two projects. (This is about the ma.’-ma~um amount of "tightening" that can possibly occur during design, and even that is veU difficult.) In the normal project development process, Stanford will be Wing to "tighten" its spaces anyhow. They are already doing this with the LPCH space program. Stanford is keenly aware that more space costs more money. They have every incentive to tighten space layouts - wh~e still presetting the functions they consider important. Impact a. of Proposed Increase in Numbers of Beds If Stanford’s patient bed projections are reasonably accurate and acceptable - then the rest of the space follows in a rational fashion and does not appear to be outside normal ranges. If the rationale for Stanford’s projected increase in new beds is not deemed supportable, then the space needs could change substantially. Stanford appears to have done solid "due diligence" in forecasting the number of additional patient care beds it needs for SHC and for LPCH. 11/7/2007 Peer Reviewer: 5’[arlene J. Berkof~ FAIA Page 26 of 26 Attachment J 1 2 3 4 5 6 8 9 10 11 12 !3 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Tasks/Event Cib’ Council initiates process for Stanford Universib’ Medical Center Contract process for environmental consultants. Be~n baseline data and "existing setting" work regarding traffic, housing, population, city services, etc. Cib sponsored communib’ meetings regarding baseline data, issues identification P&TC Study Session: review process timeline, community outreach plan, issues identification Application (conceptual) for Medical Center, including Area Plan update and land use’zoning changes Peer review of key hospital planning standards P&TC Study Session: Issues identification, project status, communib, input, and Area Plan City Council Study Session: Project Update Stanford’s community outreach and workshops P&TC review of preliminary updated Area Plan, review process, and issues summary benefits;challenges) Report to Council: review of preliminary updated Area Plan, review process, and issues summao" benefits/challenges) Formal application submittal for Development Agreement and land use changes Schematic design- input from staffand ARB ARB Study Session EIR initiation and preparation Notice of Preparation; project scoping meeting with City Council Communib" meetings- Issues discussion iP&TC Study Session- Issues discussion, Peer review, Project update City Council Study Session- Issues discussion, Project update ARB PreliminaD, Review #1 Draft mitigation measures and Development Agreement discussions ARB Preliminao’ Review #2 DEIR released P&TC / A_~_£ public heating on DEIR/APJ3 Recommendation Prepare Administrative Final EIR and Administrative MMRP FEIR / Development Agreement at P&TC FEIR / Development Agreement at Cib’ Council Tasks/Event 2006TimelineDec Timeline I ;S-Dec12006 Stanford UniversiD’ Medical Center Timeline 2007 2008 2009 Jan Feb Mar A~r J~n Ju!Au~Se~Oct Nov Dec Jan Feb Mar Apr May Jun Jul Oct Nov Dec J~n Feb Manzh 13-Aug NOP 23-Aug Jan Feb Mar Apr May Jun Jul Amz Sep Oct 2007 l -Nov 14-Nov 26-Nov Nov Jan Feb Mar Apr 2008 Aug Sept Jul Aug Sept Oct No’,"Dec Feb 2009 March 1112012007