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HOSPITAL BUILD & INFRASTRUCTURE MAGAZINE ISSUE 3 2014

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FROM DESIGN TO OPERATION,

GETTING IT RIGHT FROM
THE START
By: Conor Ellis, Global Health Leader, EC Harris/Arcadis, London, UK

here is often a misconception in health circles that projects

either dont deliver on time, to cost, or that the perceived
benefits went wrong at the construction and commissioning
stages. Most projects where we have been asked to get involved
to achieve a turnaround to better outcomes, show evidence of not
having been properly structured at the commencement. With the current
investment in healthcare its likely that healthcare expenditure in the MENA
market could easily top US$125billion by 2015. Its critical that resources
are optimised, as with any increase in population, demographics and clinical
breakthroughs, it is likely that extra funding will be needed in every country
until 2050. We often find a combination of inputs that brought together
lead to successful project delivery.The starting point should always be
writing a clear Project Initiation or Execution Plan.This should set out all
quality- and delivery issues.There should be a clear benefits proposition
that can be tested against the present operation, and then once the project
is completed.This sounds trite, but too often this stage is completed in a
superficial level of detail to be able to audit outcomes and for all parties to
be clear about strategic direction.
In this article we will examine some of the main principles that help
define outstanding outcomes. EC Harris took its learning from the
health systems in the 32 countries we work in and analysed common
issues to look for better project outcomes. The health trends for
successful project outcomes appeared to be:
l Improving clinical care and governance
l Achieving efficient Asset Management
l S ecuring FM and procurement savings by reducing hospitals
performance variation
l E ncouraging greater collaboration between hospitals, clinics and all
stakeholders
l Change public behaviours via health education.
The latter two are relatively self-explanatory but require integration
in programme design and communication between health organisations
to achieve mutual aims. The health education debate is an ongoing
worldwide phenomenon, and demonstrated by the issue of simply
adding hospital beds wont tackle the issue of obesity. As a result I will
concentrate upon the first three areas of design to operation.

IMPROVING CLINICAL CARE AND GOVERNANCE

In the case of clinical care and governance, its clear that with
approximately 70% of system costs being associated with staff issues;
reducing variability in staff performance is paramount. Schemes should
be clinically driven and patient focussed. Thorough benchmarking of all
clinical speciality areas should be applied. Successive studies have shown
that better design of primary care-led services will avoid unnecessary
admissions to emergency care by ensuring the system keeps patients out
of there unless they need to be there. On a number of schemes, both in
the UK, Europe and the USA, our teams have used simulation modelling

to predict pinch points that can demonstrate the patient flow and
logistics that need to occur to avoid unnecessary delays or inefficient use
of staff labour. As technology in many industries have shown, in the next
five years, IT and co-ordination systems in hospitals will be significantly
more able than the ones endured largely to date, being a mix of paper
and departmental systems. Real time reporting of results and speed
of data will mean transmission between localities accurately and faster,
essentially speeding up diagnosis and treatment. This means more care
at home and in the community, changing the nature of the hospital and
requiring investment in both high technology and more mobile systems.
The smartphone, amongst other devices, will undoubtedly be a large
part of this communication wave. Agreeing on suitable accreditation
framework and setting audit/outcome measures is something that the
best hospitals have in place for well-developed systems.
There are many studies (Porsche Consulting and Banerjee for
example) that show the need to rework processes given statistics
that more than a third of clinical time can be misused because of
the lack of system compliance from process breakdown (like waiting
overnight for a test result or the right equipment). This requires Lean
thinking, standardising floor units and ensuring clinical zones work
together. Cultural understanding should be interwoven and whether
one is building a new hospital in Qatar, KSA, France, USA, or Australia,
it should respond to local nuances and values, not just the statutory
compliance angles. We believe starting with a whole new hospital or
clinic policy overview and then stepping down in clinical speciality
specifications yields the right amount of project objectives aligned to
specific clinical needs. The departmental specifications then fit in line
with the objectives of the master site policy. As time progresses, the
patient is a consumer, in the same way as in all other industries will
be made aware of hospital outcomes, environmental standards and
determine their personal choice to go to the best performing units.

ACHIEVING EFFICIENT ASSET MANAGEMENT

With the data agreed with clinical staff and new Lean care pathways in
place this second stage is all about driving a site-wide solution. One

IN SHORT
l The starting point of a successful project delivery should
always be writing a clear Project Initiation or Execution Plan
l Approximately 70% of system costs are being associated
with staff issues; reducing variability in staff performance is
therefore paramount
lC
 entral procurement delivers better purchasing power than
local departments buying separately.

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some outstanding projects in the GCC. Likewise, learning from best

practice wherever it occurs is also a theme to follow. In the Ukraine the
design work we did on the plateau technique for a new womens and
childrens centre has been much admired, seeking as it does to create
hospital zones and plan efficiently the axis of cost and flexibility with
high technology areas in the core and the wards on the outside, all with
uninterrupted views. Likewise our Netherlands colleagues in Deventer
have planned a new project with 9-11% less investment than standard
due to the means of stacking.
The clever environment aspect is in reducing anxiety for patients
and speeding healing through a mixture of high- and low-technology
solutions. Its known that the interaction with plants reduces recovery
time and it is accepted that mood lighting and music improves the
mood of staff and patients. A US study found surgeons worked faster
and more accurately in Maastricht UMC, when their study showed
the Healwell system of matching light to our biological clock made
patients respond faster and increased staff satisfaction. These types of
solutions require careful planning and thought rather than simply cost.
Likewise, planning IT and equipment optimisation requires agreement
on standards and benchmarks. The design should also ensure FM is
included. In the Middle East, we too often see a condensing of ceiling
spaces for maintenance of engineering systems and a lack of regard to
how the building will function for support services. This requires more
integrated planning at the design stage.

SECURING FM AND PROCUREMENT SAVINGS BY

REDUCING HOSPITALS PERFORMANCE VARIATION

should, with fellow healthcare partners, look across localities and how
changes in primary and community care will remove some of the minor
aspects that often occur in hospitals. Agreement should be sought on
principle of occupation, ensuring that the same and similar procedures
are grouped together and treated equally in the design brief. There
is too much dedication in healthcare with specialities offered rarely
used accommodation that could be multi-purpose. Amongst the
principles of ambulatory care for example, attempt to enable facilities
that can deliver the specialist care needed, but keeping room design
planning for flexibility. Some clinicians, for example in orthopaedics,
urology and ophthalmology, often misinterpret this where there are
specialist needs for rooms that are fixed (such as slit lamps or moulds/
physio/equipment). However, even though these rooms do need to
be dedicated, they are only a small part of their overall need. The
philosophy of sizing rooms for the larger need, not having to generate
two room sizes, is growing. Theres little point having a 12m consulting
room next to a 14m minor treatment room when one doesnt know
what needs those rooms might have in three years. It is better to agree
on the larger room and allow flexibility. Projects like the Karolinska
Sweden point the way to how thinking should develop. This gives
future planning gain and enables easy transition as departments grow.
Effectively the four stakeholders of a hospital (see figure 1) have some
shared outcomes but project delivery needs to also accommodate
specific needs. A complete, successful scheme will achieve this.
All good design teams are looking to reduce travel distances,
ensure safety and build a first class environment and there are already

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HOSPITAL BUILD & INFRASTRUCTURE MAGAZINE ISSUE 3 2014

Central procurement delivers better purchasing power than local

departments buying separately. This is in part due to the specification
being overly complex and we find that differences of between 10-30%
occur through lack of clear analysis and variability in supply prices. Using
a major third party who is regularly buying achieves more efficient
outcomes. All parties have to agree to reduce carbon footprints.
Over the lifetime of a building, concentrating on improving FM
requires more attention than its currently been given by organisations.
The cost of in-use has been noted at 50-200 times the cost of capital
build. Clients need to understand bottom-up models of performance
standards, risks, maintenance regimes, and costs. We have worked with
organisations and removed structural operating risks, and by standardising
operational usage, made savings of 7-20%, whilst still meeting normally
expected good practice and statutory standards. Our bottom-up model
(Estate Cost) enables organisations to run multi-facility portfolios and
model what-if scenarios. It can then be used when looking at a particular
service such as cleaning, security or waste management to a complete
non-clinical overview at micro- and macro data levels. The key tasks are
highlighted in figure 2 and there is always a co-relation between stringent
performance standards and price; the trick is achieving a balance.
As mentioned earlier, in the UK, Germany and Netherlands, where
some hospitals and FM are funded via private contractors or PPP
concessions, lifecycle expenditure has gained more prominence as the
link between smoothing expenditure and achieving value over a longer
period has been balanced with initial risk/performance standards in
design. This requires careful selection of materials and considering asset
use, not just at the design stage, but also across the whole concession.
This thinking offers opportunities to avoid wastage, unnecessary delay or
failing buildings. It is far better to offer long-life materials such as flooring
and glazing, then FM solutions to increase cleaning and maintenance.
The selection of contractors and suppliers has several aspects
that is worthy of an article in its own right. In the GCC, we often find
that construction starts ahead of completing the design brief, with
less information on quality and outcome measures than is necessary

FEATURE PLANNING

017

qFIGURE 2: Key tasks

given the complexity of healthcare buildings. Even simple issues

like equipment interface, power and utilities needs are often being
developed with a facility under construction. As already mentioned,
the GCC has in the past been playing catch-up with a specification for
long-term maintenance that may not match the chosen build, there is
an opportunity for the new wave of hospital projects to concentrate
on integrating design, clinical process change, FM construction and
commissioning into one seamless process.
In many parts of the world we find, via our projects, the same
convergence of health business components:
lB
 enchmark data, achieve accreditation and engage clinical groups via
health planners
lP
 rincipal of EB Design such as acceptance that 100% single rooms
is beneficial
l S tandardising layouts and minimising room types for risk
and flexibility
lM
 aking multi-use function and driving out process duplication via IT
or LEAN
lC
 onsistent platforms in high tech areas like theatres and ICU
lR
 educing hazards by third party drawing review
lA
 greeing art and health benefits, light, therapy and environment
l E nsuring long life, loose fit for generic room sizes
lT
 ake a more commercial focus and make every m count
l S eparating flows of patients, staff and logistics for ease and risk, and
accept that vertical integration with primary and tertiary care is a
global trend
lR
 educing energy and CO2 admissions
lC
 onsider long-term training, research, wellness and education needs
as part of campus approaches
lP
 lan for the IT and consumer revolution
lG
 ood design offers the opportunity to implement integrated FM
lD
 rive specifications and challenges assumptions on performance of
support services
l Learn from major projects worldwide. Go visit and refresh your plans.

CONCLUSION

Is there one hospital that epitomises best practice in all the above
aspects? Not really, most of the best performing hospital groups do large
parts of this, yet even they occasionally struggle with new technology/
processes speed, politics and local stakeholders. There are a number of
hospitals in the GCC opening over the next 12-18 months that could
rightly claim to be world-class. We are lucky enough to currently work
on some great health projects in the GCC and with the lessons learnt
from global healthcare investment, the future for healthcare design,
planning and outcomes in this region is definitely a positive one.

qFIGURE 1: The four stakeholders and their needs

Audit/benchmarking
Efficiency
Total cost & supply system partners
Supply chain partners
Sustainability

Efficiency
Ratings
Insurances
Operating costs/throughput
Minimise non-pay
Sustainability

Efficiency
Outcomes
A good place to work for
Facilities and environment

Safety
Outcomes
Satisfaction
Good facilities
Calm environment
Organisation
Public space
Dignity

HEALTH
SYSTEM

HOSPITAL OR
CLINIC

STAFF

PATIENTS AND
VISITORS

REFERENCES

References available on request (magazine@informa.com)

www.hospitalbuildmagazine.com