Flagstaff Hospital Move?

The shortage of buildable land in and around Flagstaff has caught up to the needs of the community, bringing a tough decision before Flagstaff City Council. I’m no expert on the details but I do know a tough call when I see one, and I’ve been through several similar choices with clients over the years. Here’s what I wrote to Flagstaff Mayor and Council:

To: Mayor and Council

From: Ann Heitland

Re: Northern Arizona Healthcare Development Plan

Date: May 12, 2023

I have lived in the Greater Flagstaff area for 28 years and my family has had numerous experiences with medical treatment at Flagstaff Medical Center. For the most part, all of these have been positive. In addition, my wife delivered babies at FMC from 1995-2002. She then was Chief Midwife at Tuba City Regional Healthcare for 5 years, from where patients were transported to FMC as needed. We are excited by Northern Arizona Healthcare’s proposal to build a new, state-of-the-art facility to serve the northern region of our state during the next decades.

I attended the May 2 Public Hearing and subsequently read the following documents:

  1. Staff Information Memo (Tiffany Antol, Zoning Code Manager) re: Resolution No. 2023-20 and Ordinance 2023-12
  2. Staff Information Memo (Tiffany Antol, Zoning Code Manager) re: Ordinance 2023-11
  3. NAH’s Combined Application for Concept Zoning Map Amendment and Specific Plan
  4. The proposed Ordinance and Resolution
  5. The Police Impact Analysis
  6. Wildfire Fire Risk Assessment and Mitigation
  7. Fire Impact Assessment
  8. Three Standards of Cover Analysis
  9. FUSD Letter
  10. Economic Impact Analysis
  11. Draft Development Agreement (as attached to Staff’s May 2 Memo to Council)
  12. Relevant portions of the Flagstaff Regional Plan
  13. The Flagstaff Carbon Neutrality Plan
  14. The Project Narrative for the Canyon del Rio Zoning Map Amendment
  15. The Timber Sky Concept Zoning Plan Project Narrative
  16. Some of the written public comments submitted regarding the NAH Application

We appreciate all the work that City Staff has put into the NAH development project over many months. The work has certainly advanced us toward the goal of a new, wonderful health center. What strikes me, nonetheless, is that this project is vastly more significant than anything presented to the city in decades, if ever, and – while it has been handled well so far – our community deserves more attention to some of the important details before approval is granted. This was the conclusion of the Commission charged with responsibility for reviewing and recommending development and zoning projects. We hope it will be the conclusion of Council as well, and that Council will give specific direction for further staff work and negotiations with NAH.

The following are some specific thoughts and concerns. These are not exhaustive of all possible issues. I’ve grouped my comments into six bold-faced topics:

The Development Agreement Should Be Considered and Approved Simultaneously with the Concept Plan and Zoning Changes – After Adequate Review Time and Public Hearing

This was done with the Canyon del Rio Development, see Agenda June 4, 2019, items 14 A-C, and the Timber Sky Development, see Agenda November 15, 2016, item 14.

In the case before you now, the Applicant (NAH) and City Staff chose to notice the combined public hearing for the Rezoning and the Concept Plan before the notice of public hearing on the Development Agreement. The consequence of this schedule was to prevent the Public from seeing how the Development Agreement embodied promises that NAH made as part of their presentation on the Rezoning and the Concept Plan and from commenting on the sufficiency of the Development Agreement.

In Staff’s presentation on May 2, Staff recommended that if City Council approved the Specific Plan, the approval be conditioned upon full compliance with the terms of a Development Agreement. (Staff PowerPoint, 5/2/23.)  Yet, it is impossible for Council or the Public to evaluate that condition on the approval without adequate time to review and ask questions about the Development Agreement. (The staff schedule as laid out in the Amended Agenda for May 16 doesn’t sufficiently solve this problem.)

The Public Interest Demands a Thorough Assessment of the Development’s Impact on the Future of the Ft. Tuthill County Park

Rezoning must consider the impact on surrounding properties. (Finding #3) Just as a regional hospital serves a vast population beyond the City of Flagstaff, Ft. Tuthill County Park is a vital asset to our region.

I found it alarming that NAH executives had waited for five months to respond to our County Supervisors’ request for information, and that there had been no meaningful meetings between County representatives, NAH, and City Staff. (According to testimony by County Supervisors at the May 2 Public Hearing.)

The public interest in the future of Ft. Tuthill may require commitments in the Development Agreement and modifications to the proposed zoning map. Currently, we simply don’t know. In my opinion, Council cannot make Finding #3 without resolution of the County’s concerns related to this valuable adjacent property.[1]

The Public Interest Demands a Thorough Transportation Study Before Approval

The Staff Memo re: Ordinance 2023-11 states:

Accessible and convenient transportation to the new Hospital remains an unaddressed service.

As of the writing of this report, Mountain Line is not able to provide transit to the Property without additional financial resources. In the interim NAH has committed to providing 20-minute shuttle. Concerns remain for how underserved members of our community will access the Hospital, and how the relocation may affect greenhouse gas emissions from transportation service.

The present, central location of FMC provides the best opportunity for underserved members of our community to quickly reach the hospital and its surrounding medical offices and labs. Moving these services to the outskirts of town may have a significant impact on residents who already struggle with daily, essential tasks. Placing barriers in their way of accessing healthcare is problematic. A stronger effort to mitigate these barriers than NAH has so far made is required to achieve the public interest finding. (Finding #2)

Supervisor Vasquez’s testimony at the May 2 public hearing exacerbated my concerns about the present lack of information. I wondered if the Arizona Department of Transportation had been involved in planning or if consultation with them or other experts had been accomplished.

“Staff requested that NAH develop a Transportation Demand Management (TDM) plan or strategy for their project,” according to the same Staff Memo cited earlier. But staff seems to believe the City cannot compel NAH to do so and so far NAH has not. If not paid for by NAH, perhaps the City should pay for it. Without it, the evidence before you suggests this project will jeopardize the Ft. Tuthill property and may endanger patients being transported to the hospital during major events at Ft. Tuthill when traffic on I-17 and the exit ramp is backed up.  These factors should prevent you from making Findings #2 and #3 without further information. At the present time there are too many unanswered questions about the transportation impact of this project to proceed.

In the Draft Development Agreement NAH also promises “(a) continuation of NAH’s current program of providing point-to-point shuttle service for low-income persons and/or persons with mobility needs from the regional hospital to Flagstaff Shelter Services facilities and other locations at no cost to riders; (b) continuation of NAH’s current program of coordinating shuttle service for low-income persons and/or persons with mobility needs through private providers at no cost to riders.”  (Draft Agreement, 5/2/2023, Section 4.5.) However, the Draft Development Agreement also provides that NAH may entirely discontinue the private shuttle service if it reaches an agreement with Mountain Line. Id. Therefore, low-income and mobility challenged people may end up with less convenient service than they presently have. As part of the public comment process, the Taylor House wrote a letter asking NAH if their current shuttle service would be continued. The Development Agreement needs to better protect the vulnerable in our community than the current draft does.

The City’s Commitment to Carbon Neutrality as Incorporated in the Regional Plan Needs More Attention Than the Current Concept Plan and Development Agreement Provide

One of the items that stood out for me as I reviewed the two Staff Memos were these statements:

Policy Impacts:

There are no anticipated policy impacts affiliated with the proposed Specific Plan.

(Staff Memo re Resolution No. 2023-20 and Ordinance 2023-12.)

Policy Impacts:

There are no anticipated policy impacts affiliated with the proposed Concept Zoning Map Amendment.

(Staff Memo re re: Ordinance 2023-11.)

This is certainly the largest development that the City has considered since adoption of the Carbon Neutrality Plan and its associated December 2021 amendments to the Regional Plan 2030. How the City handles the application of those statements of policies and goals to this development will be precedent for future developments, so it seems to me that there are huge policy implications to be considered.

One thing I have learned in my political work over the last six years is the importance of government explaining its decisions in ways that are consistent with promises made in other contexts. Our youth are rightly cynical of government actors who make promises to address the most critical issue in their lives – the Climate Crisis – and then conduct business as usual without regard to the reality of that crisis. Yes, our community needs and deserves a state-of-the-art hospital in the coming decades but not at the cost of compromising our commitment to address the most critical healthcare issue – the Climate Crisis. We can have both if we stand by our principles. If we don’t, we face another crisis: The cynicism of our youth which threatens the very existence of democracy as we know it.

You have received numerous comments from people and organizations that are more familiar with construction methods, materials, and sustainability than I am.  Still, I can even spot unanswered questions related to NAH’s commitment to sustainability in the proposed development.

Will the shuttle service provided by NAH use electric vehicles? If not, how will that additional carbon impact be offset?

NAH offers to provide shuttle service to the nearest Mountain Line stop at a cost of $250,000 per year until Mountain Line can extend a line. If NAH is willing to commit $250,000 per year to a shuttle service, is that enough to fully equip and staff an electric vehicle shuttle service?

In spite of the multi-million-dollar cost of extending the line, I have been told that Mountain Line asked for only $800,000 to cover the cost of extending the line until Mountain Line could find permanent funding. Extending the line from the beginning will more likely encourage its use than requiring passengers to transfer from the shuttle to the bus. Council should press NAH on why it resists the $800,000 contribution in lieu of running it’s own $250,000 per year shuttle, which could go on long enough to eclipse the $800,000 expense.

NAH represented in its PowerPoint and testimony at the May 2 meeting that the new hospital and ambulatory care center would meet LEED Gold Certification. Why not Platinum? The hospital may be unable to obtain Platinum Certification because of the need for natural gas backup, but why not for the ambulatory care center – and other future buildings? What is lacking and why?

Obtaining LEED certification would cost about $50,000 where we are talking about a $1.1 billion project.  Even if the certificate costs twice that, isn’t it worth it for third-party verification of something this important?  Using as an excuse that $50,000-$100,000 will be used to invest in healthcare delivery instead, as NAH did at the May 2 hearing, is unconvincing. I think a requirement of LEED certification is reasonable.

NAH made a commitment in its PowerPoint presentation and the draft Development Agreement (4.4.3) to install solar panels on the garage by 2030.  This is good but why not at occupancy? Beyond the parking garage, there should be a commitment to install solar panels on the other structures (which NAH says in its PowerPoint are being built to tolerate the weight). Let’s install solar panels on the ambulatory care center by 2031 and on the hospital roof by 2032.  And another date for panel installation in the open parking areas as we have at City Hall.

NAH has also committed to enter a contract with APS to purchase clean energy. This must be in the Development Agreement with the requirement being to purchase 100% clean energy.

NAH proposes a minimal number of EV Charging Stations – 20 – among over 2300 parking spaces. More are needed at the outset with a commitment to add additional spaces in future years.

The May 2 Staff Presentation asserted:

  • Certain amendments to the Regional Plan in December 2021 incorporated the City’s carbon neutrality goals.
  • These amendments represent community goals and do not require that any specific project be carbon neutral.

How do we meet community goals if we do not scrutinize all projects and especially projects of this magnitude?  There are, in fact, requirements in the Regional Plan that impact the Council’s review of NAH’s Application:

Policy E&C 2.4: Promote developments that help the community achieve carbon neutrality through strategies that reduce the project’s emissions from transportation, energy, and consumption.

Policy E&C 3.6: Commit to equitably distribute the burdens and benefits of climate action policies and investments to all segments of the community.

The Council is required to consider whether this 175-acre, approximately one-million square foot development “helps the community achieve carbon neutrality” and “equitably distributes the burdens and benefits of climate action policies to all segments of the community.” Without a serious inquiry regarding this project’s impact on the community’s ability to achieve carbon neutrality in a way that equitably distributes the burden of doing so, Council cannot make Findings #1 and #2.   I submit that the Council – like the Planning and Zoning Commission – presently does not have enough information to fulfill this obligation.

A few examples of questions I don’t think you can answer: NAH asserts that the new hospital will use 45% less energy than the current hospital. Does that reduction come anywhere close to offsetting the “53,190 new daily trips” that will be added to this location on the city’s outskirts? What about the emissions arising from construction? How are they offset?  If the old hospital is repurposed, how much will the energy inefficiencies there continue; thus, cancelling the value of the 45% lower consumption in the new location?

The Council has an obligation to find that this project is overall in the public interest (Finding #2) and in compliance with the Regional Plan (Finding #3). Without a more complete Application, you cannot do so. The hospital will argue that it has done more than other projects to provide information. (I’m not sure that is true, looking at Canyon del Rio and Timber Sky.)[2] The answer to that is that this project is larger and more impactful than any other project in recent decades.

NAH has so far failed to provide sufficient information for the Council to evaluate the climate action goals that were incorporated into the Regional Plan.

Infrastructure Improvements

NAH’s May 2 PowerPoint Presentation says it has committed $45 million to infrastructure improvements. It is my understanding that Council knows that at least a substantial portion of this $45 million is intended to be covered by a U.S. Department of Transportation RAISE grant that City Staff helped NAH apply for. The success of the grant application will not be known until the end of June. The RAICES grant is a large contingency, and it seems worth waiting for that commitment before approving anything with respect to this project. 

The Economic and Social Analysis Seems Incomplete

The Economic Impact Analysis (EIA) performed for NAH and submitted in support of its combined Application concedes that hundreds of the jobs located at the new site are merely being transferred from their current location at the “Legacy Campus” and “no new employment” is associated with the “ambulatory and surgical facilities, medical office and hospital.” (EIA, p. 9.) By 2045, at full buildout of the hospital, “there could be 569 new jobs.” Ibid.

The EIA, however, argues that in 2030 a category labeled “Clinical Partners” will generate 710 new jobs and over $77 million in direct new economic impact and over $134 million of indirect impact. (Figure 5, p. 10 of EIA.)  Outside of the assertions in the tables, the only mention of “Clinical Partners” in the EIA is on p. 1 where it is said that 160,000 square feet of office space will be built for “Clinical Partners;” Figure 2 indicates construction is to be complete by 2029. But how are these Clinical Partners to be enlisted? Will their move to this new space mean that buildings in other parts of town, now surrounding the “Legacy Campus” will become vacant? The EIA fails to address this impact on the economic well-being of our community and whether or not we are simply trading jobs north of I-40 for jobs south of I-40.

The Development Agreement proposes a “Visioning Process” for the “Legacy Campus.”  In NAH’s vision, this process would not begin until January 2024, well after the NAH desired approval of its development application. And, NAH may opt out of the visioning process and proceed with development of all the “Legacy Campus” properties as high-density housing. (High-density housing seems like the right use for most of the old buildings but it would be nice to maintain some of the West Campus as a physical therapy center serving those on the northside of the city, as it does now. From personal experience, I can say that having the NAH physical therapy office in Doney Park five minutes from our home made post-surgical and other PT much easier and I would hope that the thousands of residents in the vicinity of the “Legacy Campus” would not lose that benefit.)

The point here is that without knowing what will happen to the “Legacy Campus” and surrounding “Clinical Partners” and labs, we do not have a realistic picture of the economic and social impact of this move.

We have heard many comments during public hearings from supporters of the move who are eager to avoid traveling to the Phoenix area for healthcare. I fear that NAH has set up unrealistic expectations about how much that will change. Adding 35 physical beds is not the same as adding 35 available beds – that requires professional staffing while the nation is suffering from a long-term physician and nursing shortage. NAH already employs “travelers” to cover their physician, nursing, pharmacy, and para-professional needs; building this proposed facility won’t change that. Building more workforce housing might. How economically viable is it to create further demand for “travelers?”

Furthermore, there are some medical needs that will never be treated in a regional hospital with no medical school. Highly specialized physicians who treat relatively rare illnesses are located in large urban centers because large populations provide the patient base they need to support their practices. There will always be transports to Phoenix, Las Vegas, or even Albuquerque for patients in need of such treatment. Therefore, the Council should carefully consider how much weight it gives to this justification for the NAH project.


The existing hospital is unsuitable for the coming decades. The question for Council is whether the current NAH Application serves the public interest (Finding #2) without jeopardy to other community values and goals (Finding #1) and nearby properties (Finding #3) – or is there a better way to approach this development which will come at the cost of some delay for more information gathering, better analysis, and community involvement? Based on the information presented to you so far, I do not believe that Council can make any of the required findings.

At the very least, the schedule should be reset to (1) allow public hearing and Council decision-making simultaneously on the Concept Plan, Zoning Map Change, and the Development Agreement (as has been done with other projects), and (2) await the announcement of RAISE grant upon which $45 million of the infrastructure development commitment from NAH depends. This would be an approximately one-month delay. Even more time should be required to answer questions raised in the public hearing process about transportation, safety, Ft. Tuthill, and climate action, and to begin the visioning process for the “Legacy Campus.”

Thank you for your attention. You have a tough job and I appreciate your work.


[1] According to Staff’s presentation at the May 2 meeting, Council must make three findings. The third one, per the Staff PowerPoint, says: “The site must be determined to be physically suitable in terms of design, location, shape, size, and operating characteristics; and the provision of public and emergency vehicle access, public services, and utilities to ensure that the requested zone designation and the proposed or anticipated uses and/or development will not endanger, jeopardize, or otherwise constitute a hazard to the property or improvements in the

vicinity in which the property is located.” (Emphasis added.)

[2] Incidentally, looking at Canyon del Rio’s Application and Development Agreement, one can see that they provided much more infrastructure than $130,000 for a bus stop as NAH’s attorney suggested was the case on May 2. That’s just one instance where the slick PowerPoint of May 2 may have been misleading to Council.

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