The United States has long led the world in biomedical research, and the National Institutes of Health (NIH) has been the unparalleled leader in this regard. In addition to funding investigators across the country through its Extramural Research Program, NIH has also carried out a highly productive Intramural Research Program (IRP) consisting of basic and applied biomedical and health-related research. The IRP has been a magnet for attracting highly talented scientists and trainees from across the nation and around the globe, providing the foundation for and being a catalyst to the nation’s preeminence in biomedical research. However, the ability of the IRP to continue in this vein has been challenged in recent years by a number of dynamics, including especially the aging and deteriorating condition of many of the buildings and facilities at NIH’s Bethesda Campus.
The buildings and facilities at NIH’s Bethesda Campus house the majority of the IRP and comprise a multi-billion-dollar public investment. The Bethesda Campus includes numerous laboratories; a 200-bed research hospital with a broad array of outpatient clinics; administrative space; and facilities providing research support services, energy and transportation services, and other utilities. The staff of more than 20,000, including some 1,100 principal investigators, depends on these buildings and facilities and capital infrastructure to support the highly sophisticated and often groundbreaking research conducted on the campus.
The lagging condition of the Bethesda Campus buildings and facilities received congressional attention in the Consolidated Appropriations Act of 2017, in which legislators noted that “Over time, only the most essential maintenance and repairs for health and safety have been addressed, leaving an increasing backlog of projects requiring attention.”1 The Act directed NIH to “enter into a contract with the National Research
1 Pp. 111-112 of Senate Report 114-274: Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriation Bill, 2017 (Division H of the Consolidated Appropriations Act).
Council, Division on Engineering and Physical Sciences, to prepare a report that assesses the capital needs of NIH’s main campus.”2—that is, the needs of the Bethesda Campus.
Subsequently, NIH and the National Academies developed a contract with a statement of work as follows:
At the request of the Office of Research Facilities Development and Operations, National Institutes of Health, the National Academies of Sciences, Engineering, and Medicine will convene an ad hoc committee to: (1) identify facilities in greatest need of repair or those most impacting mission implementation; (2) assess the rationale and composition of projects to bring the NIH main campus facilities up to current standards or acceptable operational performance which meet mission objectives; (3) evaluate at a high level the completeness, accuracy, and relevance of cost estimates (already developed by/for NIH) for proposed capital projects; and (4) identify potential factors and approaches that the NIH should consider in developing a comprehensive capital strategy for its main campus portfolio of facilities. It is desired that the study identify approaches based on five (5), ten (10), and twenty (20) year prioritization outlook.
In addition, to better inform sustainment of NIH’s main campus and capital planning, the study committee shall review comparable available facility condition methodologies and metrics of other federal agencies at an overall portfolio level, and provide recommendations in determining the minimum levels of funding required to sustain NIH’s assets at an overall portfolio level.
To conduct the study, in late 2017 the National Academies established the Committee on Assessing the Capital Needs of the National Institutes of Health. During its deliberations, the committee spent substantial amounts of time at the Bethesda Campus. This included inspecting the Clinical Center, the Porter Neuroscience Research Center, the dedicated animal vivarium (i.e., the Building 14/28 complex), the infrastructure core (including the combined utility plant, industrial water storage, and thermal energy storage tanks), and specialized laboratory spaces (including bioinformatics). The committee interacted with multiple directors of institutes and centers (ICs), the director of the Office of Research Facilities, and other NIH officials, as well as officials from other federal agencies with responsibility for asset management. The director of NIH, the deputy director for management, and the deputy director for intramural research all spent time meeting with the committee. This report describes the findings and recommendations of the committee.
NIH BETHESDA CAMPUS: FACILITIES AND ACTIVITIES
The 310-acre Bethesda Campus of the National Institutes of Health includes a large intramural research program nested within an administrative structure that offers central oversight over all NIH activities—intramural and extramural. The intramural programs are located on the Bethesda Campus and adjacent sites (with a few exceptions), whereas the extramural programs are performed by academic and other research institutions across the nation.
The history and culture of NIH, and especially the Bethesda Campus, have a material bearing on the comprehensive capital strategy for the campus portfolio of facilities. Extraordinary advances in the treatment of common and rare diseases have been made at NIH, and its scientists continue to expand the boundaries of knowledge about human biology and disease. Through its intramural and extramural research programs, young investigators are schooled in the disciplines of performing research and reporting research findings. As the information technology revolution has taken hold over the past 50 years, NIH scientists and researchers have brought the world’s health-related literature into the hands of researchers, practitioners, and citizens worldwide. Overall, NIH is a critical national resource that is essential to medical science and to national security relating to health.
2 The NIH Office of Research Facilities and the National Academy of Sciences subsequently entered into a contract on September 30, 2017.
The structure and organization of NIH, in comparison to most other biomedical research organizations, is driven by government funding, political as well as policy support (particularly from the legislative branch), and strong external public advocacy groups. The NIH director oversees a confederation of 27 disparate ICs with vastly different space requirements (see Figure S.1), rather than a centrally controlled organization. The missions of the institutes themselves, in colloquial language, mostly relate to parts of the body and health conditions such as eye and heart health, cancer, aging, allergies and infectious diseases, and neurological conditions. Complementing such institutes is the work of the Clinical Center, which links patient care with basic research discoveries and programs for the study of undiagnosed diseases and rare diseases and conditions. In addition, various core support services are provided on campus to the ICs. For example, the Division of Veterinary Resources manages 11 buildings totaling 300,000 gross square feet of animal housing and laboratory space, as well as 7 buildings totaling 150,000 gross square feet of animal housing space at the 513-acre NIH animal center in Poolesville, Maryland. The DVR provides housing for approximately 100,000 animals. The core support services recently became a focus of the IRP, which, in 2017, adopted the NIH-wide Collaborative Research Exchange (CREx)—a marketplace connecting IRP investigators with more than 110 IRP core capabilities and external vendors.
The committee believes that the peculiarities of the NIH organizational structure and the nature of its funding streams present a number of unique challenges in managing the buildings and other capital assets on the Bethesda Campus, as discussed below. A little more than one-tenth of the total NIH budget supports the Bethesda Campus, although comparatively, the budgets for research facilities and related infrastructure at the NIH Bethesda Campus have not kept pace with the capital asset investments of a number of similarly focused enterprises that now compete with NIH in biomedical research.
Today, biomedical research facilities are supported by architectural and engineering solutions that prioritize flexible and adaptive space, shared facilities, and multiple, diverse, and often social spaces in which teams of differing sizes and composition can pursue investigations. Public and private organizations are also considering alternative capital asset management approaches for their research facilities to avoid accelerating obsolescence and “stranded space capital assets,” identifying strategies that will maximize the deployment of increasingly scarce capital financial resources, and most importantly, remain competitive in retaining and recruiting current and future scientists to sustain impactful discovery research.
In recent years, NIH has begun integration of the IC’s intramural resources and programs to foster collaboration. Some recent developments in this regard were evident during the committee’s visits to the campus. For example, the John Edward Porter Neuroscience Research Center, which opened in 2004 (with a second phase opening in 2014), is a state-of-the-art 500,000-square-foot energy-efficient life science facility that brought together under one roof 800 scientists and 85 research labs from 10 ICs. Other shared facilities include a peptide sequencing facility, a magnetic resonance imaging suite, and a light imaging facility. Similarly, NIH’s data science and high-performance computing infrastructure has been greatly expanded in the past 5 years in response to the increasing data infrastructure needs of IRP investigators. Notwithstanding these important developments, the committee felt that considerably more could be done at the Bethesda Campus to promote a more flexible, collaborative, and integrated research milieu.
The buildings and facilities at the NIH Bethesda Campus are in need of significant improvement and upgrading to sustain their current mission and ongoing functionality. The 12 million facility square feet have an average Condition Index of 83.3, which is considered poor.3 Seventy-two percent of the facilities are more than 20 years old, and much of the supporting infrastructure is significantly older. The Backlog of Maintenance and Repair (BMAR) as tracked by NIH and briefed to the committee is $1.3 billion and growing rapidly due to insufficient annual funds to keep pace with needs. These needs include upgrading power and water distribution systems, roof repair and leak mitigation, road and parking improvements, and enhancing safety and security infrastructure.
Over the past 20 years, a number of individual facilities have been funded by congressional appropriations for defined uses, but funding has not adequately addressed the overall BMAR needs. The congressionally controlled Buildings and Facilities (B&F) account, requested in the President’s budget and appropriated by Congress, has been stagnant at or slightly above $100 million for approximately 15 years (Figure S.2). This level of spending has not been sufficient to address the overall campus needs. The fiscal year (FY) 2019 B&F account increase to $200 million, kept level-funded for FY 2020, is not sufficient to match the current annual growth in BMAR and is wholly inadequate to reduce the previous years’ backlog.
The committee recommends a total of $1.3 billion in new funding to address the Bethesda Campus’s needs to upgrade its buildings and facilities. The committee believes that this new funding should be allocated in two tranches. An initial tranche in the range of $700 million should be made available as soon as possible for the purpose of replacing or improving infrastructure serving current and future facilities and their associated science (Recommendation 4.1). A second tranche of some $600 million should be made available in accordance with further assessment of various facilities within the context of an updated overall campus Master Plan (Recommendations 4.1, 5.1, and 5.2). The committee further recommends policy changes to the B&F funds to protect a sustaining level of funds (Recommendation 4.2) to focus on future BMAR reduction and to create a recurring annual plan to identify specifically how that reduction will occur (Recommendation 4.3).
3 Condition Index is defined as the difference between the replacement value of an asset and the BMAR, divided by the replacement value.
Recommendation 4.1: The currently identified $1.3 billion in the Backlog of Maintenance and Repair (BMAR) should be funded in two tranches. First, fund the entire long-term infrastructure improvements totaling approximately $700 million over a specific time period (e.g., 5 years) so that a comprehensive plan can be undertaken to support the ongoing research activities and begin preparation and support for any future Master Plan improvements. (The full title is “2013 Comprehensive Master Plan—Bethesda Campus.”) Second, the remaining $600 million needs to be considered for each building in light of its future as defined in the approved Master Plan.
Recommendation 4.2: The Buildings and Facilities account, or other account, should have an annual dedicated investment amount—determined by considering the amount of Backlog of Maintenance and Repair (BMAR), building condition index, and historical levels of spending—for reduction or elimination of BMAR that can be used only for this purpose.
Recommendation 4.3: NIH should adopt and implement a Deferred Maintenance and Repair program focused on building and utility system condition data that will minimize or eliminate specific failures that are disruptive to mission accomplishment and to reduce Backlog of Maintenance and Repair while attaining the building Condition Index (CI) target stated in the Master Plan. The methods that the committee recommends for capital planning prioritization—that is, incorporating CI and mission dependency—can be adapted for this purpose.
CURRENT CAPITAL ASSET MANAGEMENT AT NIH
Asset management in any large research campus environment is a challenging process; however, the challenge at the NIH Bethesda Campus is more than most, for a number of reasons. The B&F account, noted above, has numerous interests vying for its use, ranging from system repair, to adapting space for scientific research equipment, to office reconfiguration, to utility and life safety updates. There is no funding dedicated to retiring BMAR. NIH’s organizational structure of 27 individually funded ICs makes achieving consensus on the future and capital assets planning extremely difficult, especially as it relates to common-use resources such as facilities in the Clinical Center, the Building 12 Data Center, and the dedicated animal vivarium (i.e., Building 14/28 complex) and vivariums co-located in research buildings.
The variety of funding streams that NIH’s internal Facilities Working Group (FWG) must pursue complicates the prioritization process. Large projects are queued and prioritized through a 1,000-point system and then advanced to a point of submission readiness to apply biannually for nonrecurring expense funds, repurposed and redirected at the Department of Health and Human Services-level, or to solicit congressional funding. Monies from the B&F account are used to advance these projects rather than to address sustaining current operational needs. It was not obvious to the committee how this process considers the balance of the overall campus needs when prioritizing funding requests. Understandably, it is difficult to get financial donors interested in funding repairs and utility upgrades over a new high-profile building.
The Bethesda Campus utilizes an annual building and utility system assessment process that identifies a Condition Index for each building. However, there seems to be missing in this process an indication of functional value. The committee has identified a number of federal research programs (e.g., MIT Lincoln Laboratory, Naval Research Laboratory, Johns Hopkins University Applied Physics Laboratory, and U.S. Army MEDCOM) that have utilized this concept of functional value to better inform their needs and to help make the often difficult decisions that are required in a funding-constrained environment. Disruptions of work at the NIH Bethesda Campus occur not infrequently due to building componency failure and deterioration. The committee recommends that functional value be included as a much more highly rated variable in the decision making system (Recommendation 5.1). It is recommended that the FWG review and learn about this process from peers at the above-noted or similar organizations (Recommendation 5.3). This limitation of NIH’s current capital asset management practices was repeatedly noted by the committee. To remedy this, the committee recommends wider engagement of NIH with planners and practitioners in other organizations. These upgrades and repairs to existing buildings/systems should be considered alongside the Master Plan needs for new facilities (Recommendation 5.2). With the consideration of the above inclusion into the scoring system, the committee recommends that the assessments be reconsidered to determine if the prioritization remains the same (Recommendation 5.1).
Recommendation 5.1: NIH should revise its Building and Facilities (B&F) prioritization model so that a significant portion of the 1,000-point scoring system (no less than one-third of the total points) includes the Condition Index and Mission Dependency Index as objective parameters. Using this revised model, NIH should reassess all current projects in the 5-year B&F plan. The balance of the $1.3 billion of funding (i.e., $600 million) should be prioritized based on this assessment. This assessment could also be used to determine the annual required funding set aside.
Recommendation 5.2: NIH should utilize the changes in the Building and Facilities prioritization model to complete an analysis of projects to modify or replace Building 12, the Building 14/28 complex, and various active or planned projects to renovate or replace portions of Building 10 occupied by the Clinical Center. If the analysis supports a high priority for these projects, then NIH should continue with efforts to move forward as quickly as possible with these projects.
Recommendation 5.3: NIH should seek out the federal agencies referenced in this report, along with other similar agencies, to determine if there are best practices that it can utilize. NIH should
consider regular (e.g., quarterly) engagements with these agencies to review its Capital Asset Management Program, as well as how the engagement of key individuals from the institutes and centers (at all levels of the organization who are impacted by the program) and the private sector could enhance the success of NIH projects.
NIH APPROACH TO MANAGING ITS BETHESDA CAMPUS BUILDINGS AND FACILITIES
In 2015, NIH developed a comprehensive Strategic Plan designed to synchronize research program priorities and support forward-thinking decisions across the 27 ICs. The document, NIH-Wide Strategic Plan Fiscal Years 2016-2020: Turning Discovery into Health, establishes four objectives: (1) advance opportunities in biomedical research; (2) foster innovations by setting NIH priorities; (3) enhance scientific stewardship through recruitment, partnership, and management; and (4) excel as a federal science agency by managing for results (NIH, 2015c). However, the NIH-Wide Strategic Plan did not establish enterprise-wide priorities, and this committee is not aware of any detailed implementation plans for the identified strategic objectives, particularly the ways in which the research strategy depends upon specific building or infrastructure facilities, space utilization policies, or capital investment strategies. As outlined in the document Long-Term Intramural Research Program Planning Working Group Report (NIH ACD, 2014),4 the IRP has an important role to support the full integration of the NIH biomedical research effort. This integration role may require changes in the IRP structure and culture to support team science (including local, national, and international collaborations), as well as state-of-the-art research facilities, with an emphasis on facility and research infrastructure integration and optimization.
A further NIH-authored document, 2013 Comprehensive Master Plan—Bethesda Campus (NIH ORF, 2013), or “Master Plan,” has four implementation strategies that could be paraphrased as follows: (1) advance NIH’s Strategic Research Initiatives; (2) replace aging capital facility assets; (3) reduce NIH’s leased space; and (4) resolve regional traffic congestion. In particular, the Master Plan emphasizes the renovation of outdated research facilities and the construction of new administrative space to accommodate employees residing in leased space on campus. It also proposes to organize the Bethesda Campus into five research clusters to facilitate collaboration and create opportunities for development of multi-institutional centers and address other trends such as computational biology. This committee was unable to find any formal process that establishes an integrated proactive management practice that explicitly links the NIH-wide research strategies to facility management and planning efforts—a process that, if implemented, could facilitate timely updates to accommodate rapidly changing research directions, processes, and methods.
The NIH Office of Research Facilities (ORF) manages the current capital investment planning. The ORF processes for repair and improvement include identifying and prioritizing specific projects annually, perhaps as often as quarterly, based on regular meetings among ORF maintenance and operations subject matter experts and other technical staff. The NIH ORF also manages capital cost models for projects on the Bethesda Campus in response to specific requests from the 27 ICs throughout the year. Based on project cost materials provided, the committee finds that the current cost estimates are generally consistent with information required of NIH from the U.S. Department of Health and Human Services Facilities Program Manual (Volumes I and II) guidelines and uses consistent general capital cost categories. However, inconsistent metrics appear to exist within key NIH Capital Cost Template cost model line items. These inconsistencies do not appear to be based on typical variables, including geographic factors (e.g., seasonal or [clinical or research] operations schedule requirements or labor conditions impacts), construction cost scale of a project, project duration due to construction or regulatory entitlement processes, capital cost escalation factors, project complexity, construction phasing, acquisition of major equipment components, or other variables among individual capital projects.
The committee believes that NIH would benefit significantly from an explicit integration of its research Strategic Plan with its capital facility asset management plan, with clear prioritization relating the long--
4 Authored by a working group of the statutory NIH director’s Advisory Committee.
term research strategy to the 20-year campus Master Plan. This integration may also include a rigorous and detailed 10-year deferred maintenance backlog reduction plan integrated within a 10-year major capital improvement plan. Such plans would require annual redevelopment and review and adoption at the highest levels of NIH (Recommendation 6.1). Both the NIH-wide Strategic (Research) Plan and the campus Master Plan, discussed above, emphasize the importance of enhancing interactions and collaboration among IRP research personnel and partners through shared space and facilities, and the need for flexible and adaptable facilities to accommodate these collaborations and rapidly changing research program needs.
As noted in the April 2016 report Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research: The Clinical Center Working Group Report to the Advisory Committee to the Director, there was “no independent entity to verify that engineering controls for high-risk facilities meet appropriate regulations or standards prior to or after construction.” (NIH ACD, 2016) The committee believes that NIH would be well served by establishing a formal third-party (external) peer review of the NIH ORF planning documents (including cost models) from the very earliest stages of the capital planning process to completion and reassessment of the capital facility asset portfolio (Recommendation 6.2). Here again, the committee sees value in wider engagement of NIH with planners and practitioners in other organizations (see also Recommendation 5.3).
Recommendation 6.1: NIH should integrate its research strategic plan with its capital facility asset management plans, with explicit prioritization aimed at relating the long-term research strategy to the long-term campus Master Plan. This integration should include a rigorous and detailed 10-year plan for reduction of its Backlog of Maintenance and Repair that is embedded within the institution’s major capital improvement plan (currently the Buildings and Facilities/Nonrecurring Expenses Fund-funded 5-year plan). These plans should undergo annual review, redevelopment as needed based on review, and adoption at the highest levels of NIH.
Recommendation 6.2: NIH should establish a formal external interdisciplinary peer review panel to provide ongoing review of NIH capital assets, the annual project plan, the 5-year plan, the master plan, and the integrated research strategic plan and master plan, including enhancing interactions and collaboration among Intramural Research Program research personnel and partners.
Recommendation 6.3: NIH should establish processes and a system that ensure third-party, expert peer review of all adopted Office of Research Facilities preplanning programs of requirements and total project capital cost models.
FUTURE NIH APPROACH TO PLANNING
NIH is one of many government scientific research agencies that must strategically align the availability of facilities with its real estate portfolio to achieve organizational goals, while contending with constrained budgets and rising facility operating costs and responding to technological and socioeconomic drivers and federally mandated compliance requirements. Facilities asset management has been defined by the National Research Council as “a systematic process for maintaining, upgrading, and operating physical assets cost effectively.” It combines engineering principles with sound business practices and economic theory and provides tools to facilitate an organized, logical approach to decision making.
The committee benchmarked NIH’s capital asset management against a handful of federal agencies with scientific research missions. Overall, capital facilities planning leadership and management continues to be led by the research scientist community and, with few exceptions (e.g., U.S. Department of Agriculture Agricultural Research Service), has not collaborated with the capital facilities financial and technical staff (e.g., engineers, architects, planners) as peers, but instead views them as “staff support.” In the process of
benchmarking, the committee also identified a need for greater engagement and sharing of information with these other agencies (see Recommendation 7.3, below, and also Recommendations 5.3 and 6.2, above).
The committee also considered recent trends in capital asset management. Research institutions are utilizing multiple and innovative financial instruments, including debt capacity analyses, philanthropy, increasing the relocation of operating budget resources to capital budgets to provide additional cost participation from noncentral institutional funds, use of shared core facilities, and outsourcing core facilities (including animal care facilities), lease and buy back, and other capital development strategies that do not use scarce institutional capital resources. Another capital development strategy utilizes public/private capital or private sector-only financial funding sources for parking structures, dry research laboratory, animal care facilities, and administrative office, food service, residential housing, utility infrastructure, and other capital projects (including public safety, day care, and other “amenities”) associated with the biomedical research enterprise.
Due to the accelerating competition for capital resources in both the private and public sectors of the national and global research enterprise, the role of capital facilities financial planning is recognized as a critical component requiring subject matter expertise within central administrative leadership to support institutional financial sustainability. In addition, more comprehensive capital facilities plans and capital project reviews are required to achieve a more highly integrated capital and scientific program decision making model that is more quantitative, objective, and able to withstand external peer review.
Recommendation 7.1: NIH should study the non-NIH federal research programs described in this report, among others, and incorporate or adopt, where appropriate, functionally similar assessment, prioritization, and funding strategies for the purpose of better meeting facilities and infrastructure investment needs.
Recommendation 7.2: NIH should implement a capital facilities planning governance structure, functionally similar to that utilized by other scientific agencies noted in this report, aimed at facilitating an integrated, transparent, and inclusive capital asset planning decision making process. This governance structure should facilitate tracking the agency’s progress toward achieving its strategic and programmatic objectives.
Recommendation 7.3: NIH should convene an annual capital facilities planning workshop or similar forum with other federal agencies and academic research institutions for the purpose of assessing NIH capital asset management program processes and identifying improvements, including the ongoing development of a capital financial resource sustainability plan. The proceedings of this workshop and any recommendations should be distributed to the institutes and centers and central administrative leaders, among others, and be used to inform Intramural Research Program budget development. There should be broad participation in the workshop, including by principal investigators, junior faculty, and research laboratory staff; capital and operating budget staff; information technology leaders; capital planning staff; campus infrastructure operations staff and maintenance leaders; and representatives from other federal agencies and academic research institutions.
Recommendation 7.4: To verify the presence of subject-matter expertise within its core administrative leadership, NIH should review and consider whether its organizational structure ensures that its Bethesda Campus scientific research and capital assets management strategies and plans are aligned. In doing so, NIH should consider how other federal agencies with research missions have accomplished this end by assigning a senior organizational leader with such responsibilities and empowering that person with commensurate authority.
THE EVOLVING GLOBAL BIOMEDICAL RESEARCH ENVIRONMENT: IMPLICATIONS FOR NIH AND ITS CAPITAL ASSETS
Significant changes have occurred over the past several decades in how biomedical research is conducted and who is conducting it. The dominant paradigms of the past have been replaced with a new overarching paradigm for research that is broader and is “biopsychosociotechnical” rather than simply “biomedical.” This paradigm recognizes that positive impacts from research on human health proceed from understanding and successfully impacting all relevant biological, psychological, sociological, and technological dimensions relating to the condition. The concept of “team science,” defined as a scientific collaboration by more than one individual in an interdependent fashion, has evolved because of the increasing need to bring experts from multiple disciplines together to address complex problems. Having flexible and adaptable contemporary biomedical research space is essential to accommodate the current and future needs of multidisciplinary research teams.
Recommendation 8.1: NIH should explicitly prioritize the initiatives specified within the NIH-wide Strategic (Research) Plan and the 2013 Bethesda Campus Master Plan (or its successor), which emphasize the importance of enhancing interactions and collaboration among Intramural Research Program research personnel and partners through shared space and facilities, and the need for flexible and adaptable facilities to accommodate such collaborations and rapidly changing research program needs. This should apply to existing facilities as well as new facilities, and through further enhancement of key strategic shared core assets such as Biowulf and the Clinical Center.
The NIH Bethesda Campus has supported best-in-class biomedical and clinical research for decades. The ability of the campus’s IRP to continue in this vein has been substantially challenged in recent years by the deteriorating condition of many of the NIH Bethesda Campus buildings and facilities. To address this growing problem, NIH will need a substantial infusion of funding to bring the condition of these buildings and facilities to an acceptable level. In the future, it will need to spend available monies so as to avoid yet another buildup of deferred maintenance and, in its planning process, give more weight to functional value of the facilities that are the beneficiaries of proposed improvements and build-outs. NIH’s stewardship of its buildings and facilities has proven flexible and adaptable, and, with sufficient resources and improved asset management practices, it should be able to meet the evolving needs of its biomedical and clinical science enterprise.