Hospitals, clinics, and similar facilities are among the most demanding an engineer can tackle—the technology is evolving rapidly, hospital managers are increasingly budget-conscious, and assist in saving lives.
By Consulting-Specifying Engineer
CSE: What’s the biggest trend you see today in health care facilities and medical campus projects?
Andrew Flanagan: Health care campuses are complex, evolving systems that transform with best practices for patient care, technological advances, and large-scale politics. From a mechanical, electrical, and plumbing (MEP) perspective, both existing and new facilities seem to be focusing on robust, low-maintenance core systems to allow several generations of retrofits throughout their usable square footage with minimal impact to adjacent departments. It is essential for these core MEP systems to be scalable and work at various duty points for the management of the health care facility.
Mikhail Fuks: The biggest trend is the continued movement for more outpatient facilities across all health care providers. These facilities are no longer in traditional campus layouts; instead, they are moving into retail centers, mixed-use high-rises, and medical office buildings disconnected from the central campuses.
Gary Hamilton: Health care facilities are changing quickly, but the pace of technological change is outstripping the rate at which we can make alterations to our existing medical facilities. The next generation of health care buildings will be very different from the hospitals, medical offices, and clinics that we are familiar with today. A revolution in building design is already upon us, prompted by an acceleration of technological innovation, rapidly aging populations, changing expectations of how health care should be provided, and a growing realization that the environment is an important part of the healing process.
Alex Harwell: A focus on catching up existing anchor facilities from the past decades of deferred repair and renovation projects. We have seen a much-needed shift of the capital pendulum from new construction to reinvestment in critical older facilities.
George P. Isherwood: We see a trend toward medical office buildings and ambulatory centers (23-hour-stay facilities). We also are seeing significant investments in new infrastructure for aging facilities due to hospital system mergers.
Jeremy Jones: Many health care systems in our area are increasing their focus on behavioral health populations. These patients have very special needs that require them to be separated from the general hospital population. Some health care systems choose to implement a behavioral health wing, while others choose to care for those patients in a separate facility. Preventing self-harm by these patients is also a major concern for health care systems and their design teams. There are multiple anti-ligature products and strategies available in the market to provide a safe environment for behavioral health patients while preserving their dignity. It does take significant foresight and planning on the part of design teams, however. The adoption and mandatory compliance with USP 800: Hazardous Drugs-Handling in Healthcare Settings is resulting in a very steady stream of pharmacy upgrade and/or replacement projects. Much of this new standard involves the handling of pharmaceuticals, but there are MEP implications as well, such as an increased focus on filtration, dilution, and proper pressurization. Some clients are purchasing modular pharmacies and integrating them into existing facilities, while others are engaging in major renovations. The deadline is looming, and most hospital systems will require major upgrades.
Brian Kannady: One trend I have noticed is the construction of multiple, smaller facilities. It seems that health care systems are trying to bring services to patients, rather than forcing patients to travel to a more traditional downtown campus. These smaller facilities can have both primary care and specialized functions including ambulatory surgery, imaging, or acute care.
CSE: What trends are on the horizon for such projects?
Hamilton: Patients armed with information about their conditions are already informed consumers of clinical care, rather than passive recipients, and they will increasingly want to access services on smartphones and mobile devices. But the impact of technology will go far beyond simply providing mobile apps so patients can have basic interactions with doctors or book appointments. The revolution will be driven by a combination of the widespread use of networked smart sensors, vastly increased computing power, better telecoms, improvements in robotics, and strides forward in artificial intelligence (AI), together with algorithmic computer decision-making.
Harwell: Holistic system analysis for prioritization, timing, and coordination of large-scale equipment replacements will be necessary to meet many owners’ expectations of the practical and effective use of their repair and improvement dollars. This will likely materialize in increased predesign condition assessments and studies for those facilities, with the vision and capital to implement a strategy rather than a response.
Isherwood: We believe developers who usually don’t work on health care-related facilities are moving into the marketplace for these types of buildings.
CSE: Are you noticing an increase in the building of new projects, versus retrofitting existing buildings?
Harwell: This question is coming up, as it should, for many large-scale projects. However, at least in my experience, there is still significant investment being channeled to existing facilities in lieu of new, replacement construction for the anchor facilities. For older and smaller community facilities where land may be relatively affordable and/or the market base has shifted away, new construction continues to be the preference. The driver for this decision is often varied and not necessarily solely dependent on the first cost of construction. Some facilities have developed a specific reputation, team, or location that particularly works for that system, which can outweigh potential savings in relocation to a new-construction facility.
Hamilton: There is a bit of both. There are much more medical office buildings being constructed in more rural communities to expand the footprint of some health care systems. Some health care systems also have small prompt-care and urgent care locations in strip malls and other areas where the locations can facilitate community care.
Jones: I wouldn’t characterize what we’re seeing as an increase in new construction, but there certainly hasn’t been a decline. The market is strong. Many were predicting that the Affordable Care Act would force consolidation, limit health care system spending on facilities, and shift the focus to retrofit of existing assets over new construction. That hasn’t really occurred.
Flanagan: Health care organizations aim to make the most out of their existing infrastructure while remaining adaptable and looking for opportunities to constantly evolve health care delivery. New facilities focus on delivering a host of primary care offerings closer to the consumer with clinics and medical office buildings. Existing large hospitals continue to manage, maintain, and extend the life of existing infrastructure to provide in-patient beds and services while performing retrofits to increase the patient experience.
Fuks: Currently, more existing buildings are being retrofitted to buy time as the health care market becomes clearer from the standpoint of federal policy, state seismic mandates, and procedure reimbursements from insurance companies.
CSE: Tell us about a recent project you’ve worked on that’s innovative, large-scale, or otherwise noteworthy. In your description, please include significant details-location, systems your team engineered, key players, interesting challenges or solutions, etc.
Hamilton: I am currently designing a 300,000-sq-ft community hospital for the Allegheny Healthcare Network in Pittsburg. The main engineering innovation associated with this project is the use of a modular central utility plant (MCUP) to solve the challenge of the lack of program space in the hospital building to locate a plant. This plan was designed to contain chillers, cooling towers, boilers, water-treatment systems, pumps, heat exchangers, pressure-reducing stations, variable frequency drives (VFDs), and controls. This type of plant is ideal for this project because the plant was designed to be expandable to meet the requirement of future needs and also handle the cooling and heating load of an existing medical office building if needed. The hospital is designed to be a 110-bed, Day 1 facility, with plans to expand to 170 beds in the future. While the MCUP is designed to meet the requirements of a 120-bed hospital, only modules with a capacity to serve Day 1 loads will be installed initially. The complete MCUP will include four chillers, three steam boilers, three hot-water boilers, and four cooling towers, whereas the Day 1 installation comprises three chillers, three cooling towers, three steam boilers, and three hot-water boilers along with the supporting accessories. Thus, the upfront capital costs are only spent on the equipment and associated enclosures that are needed to support Day 1 loads. HKS is responsible for the planning and architecture and Gilbane is the construction manager for the project.
Flanagan: In the past decade, Interface Engineering has provided the MEP design services and delivered two large-scale LEED Platinum facilities for Oregon Health & Science University. The Center for Health and Healing is a 400,000-sq-ft facility built to house a variety of lab, ambulatory, and rehabilitation functions. The core and shell of the building were completed in 2006 and featured a host of core MEP systems including onsite sewage treatment, rainwater harvesting, airside and waterside heat recovery, daylight harvesting, and solar-photovoltaic and thermal energy collection, all feeding into robust core hydronic and plumbing distribution. Tenant Improvements continue through today as the organization works to keep up with the evolving demands of health care delivery. The second facility, the Collaborative Life Sciences Building, is a 650,000-sq-ft facility built to house a variety of lab, research, and learning functions.
Kannady: Not one specific project, but rather several projects of similar type that we have recently been a part of. These projects are a combination of health care practices or systems, professional or collegiate sports programs, and a university system. These buildings are unique in that they can provide sports medicine, imaging, physical therapy, and sports performance to the elite or collegiate athlete and may have a research component. There are many challenges in this type of project (codes, design standards, information sharing, etc.), but they offer a unique opportunity to provide multiple services in a single location.
Isherwood: PBA provided MEP engineering design services for a 6-story critical care tower for DMC Children’s Hospital of Michigan. The new tower used lean design principals, which included building cardboard walls in an unused ice area for the users to walk through and test different layouts to ease workflow patterns.
Harwell: We have recently completed smoke-control system assessments of multiple, existing older hospitals with systems dating back to the 1950s. The charge was to provide a complete picture of the installed smoke-control systems across the facilities including where they are, how they are supposed to work, and how to test them in accordance with the current NFPA standards. This included exhaustive field and drawing investigations to identify, inventory, and assess both the systems found and what may be required for the structures they serve. These assessments included evaluations of not just the current applicable codes, but also those that were in place at the time of the portion of the facilities’ construction. We followed this by generating system maps, one-lines, and sequence-of-operation summaries to provide the facility with the tools needed to maintain these systems going forward.
CSE: Describe a stand-alone medical facility, such as a surgical center, that you worked on recently. Describe its challenges and solutions.
Fuks: We recently completed construction on a new 4-story medical office building for urgent, primary, and specialty care functions in downtown Los Angeles. The project also included building a new parking structure and connecting all site buildings onto the same electrical power service with site distribution. The project was challenging due to the tight aspects of the site for building placement, utility distribution, and the speed of construction. The construction phases were divided into superstructure, shell/core, and tenant improvements, but multiple phases were in design at one time and construction overlapped as well. Our team had to work hard to stay coordinated between the different design and construction activities to stay on schedule.
Jones: Most of my recent new-construction projects have been major expansions of existing campuses. However, the unique challenges placed on stand-alone surgical centers are primarily related to the fact that they are remote from the major, shared infrastructure of a large campus. Established medical centers have made investments in emergency power generation, central utilities (chillers and boilers), and other infrastructure, such as medical-gas farms, etc. When an expansion or new building is added to these campuses, tying the new construction into the existing infrastructure comes with an expense, but you don’t have to reinvent the wheel. For a relatively small stand-alone surgical center, creating this infrastructure from scratch requires a proportionally higher investment. For example, consider a surgical center with a 1,000-ton cooling load. If that building is added to an established campus with a lineup of existing chillers with N+1 redundancy, the project will involve adding a 1,000-ton chiller to the existing system. If that facility is a stand-alone building, however, the project would involve something like three 500-ton chillers or two 1,000-ton chillers to provide a similar level of redundancy. That’s a 50% to 100% increase in equipment costs. The same logic would apply to most major infrastructure where redundancy would be best practice. The result may be stand-alone facilities where cost considerations lead to no redundancy or reduced redundancy.
CSE: How are engineers designing such facilities to keep initial costs down while also offering appealing features, complying with relevant codes, and meeting client needs?
Jones: The best way to manage costs in health care is by prioritizing substance over style. We recently had an owner say to the potential design teams during a pre-proposal conference, “If you want the building you design for us to be on the cover of a design magazine, you need to go work for someone else.” The idea was that patients generally have choices when deciding which health care provider to use. While they obviously want a comfortable and clean environment, if the hospital looks extravagant and expensive, with high-end finishes, patients and their families are much more likely to attribute a portion of their high medical costs to the cost of the opulent facility. For us, that means that a reasonable portion of the budget can be reserved for what is important to engineers, such as energy efficiency, maintainability, redundancy, resilience, etc.
Isherwood: Property developers are moving into the medical office building (MOB) arena with design standards that are more orientated toward a shorter-term lease, rather than a hospital that is built to last for several years. The developers are lining up the doctor groups and providing a revenue-generating facility. It will be interesting to see how sustainable these facilities will become in the long term.
Fuks: Design is moving more toward prefabricated assemblies for field installation. This is to minimize the time spent onsite to complete the installation of a system and increase the number of activities that can happen at once while offsite.
CSE: Have you worked on any such projects for overseas clients? If so, how have you found project requirements compare between the United States and other countries?
Isherwood: Our overseas work has comprised bringing U.S. code compliance to less developed countries-designing to U.S. code in comparison to the home country code.
Jones: There are certainly international project expectations that vary greatly from what we see in the United States. We recently worked on a project in Europe, and during tours of their existing facilities, it became clear that the baseline expectation for patient-room HVAC was an open window. Absolutely zero HVAC beyond a radiator beneath the window. Interestingly, their benchmarked infection data was no higher than our heavily ventilated and filtered U.S. patient rooms. Establishing appropriate construction budgets and aligning standards in such an environment can be a challenge.
CSE: How has your team incorporated integrated project delivery (IPD) or virtual design and construction (VDC) into a project? Define the owner’s project requirements and how the entire team fulfilled them using these methods.
Jones: We are finally seeing this trend make its way to the East Coast. Our office’s first true IPD project with a multiparty contract is in the middle of construction on a major hospital expansion in Greensboro, N.C. All profit for the major partners (architect, general contractor, MEP engineer, structural engineer, major trade contractors) is 100% at risk based on meeting the project’s financial goals. At the end of the day, each partner will receive the same percentage of their portion of the profit pool. This is creating an environment that is breaking down the traditional barriers between our individual firms. When a problem arises in the field that would be a change order in a traditional contracting method but is now a threat to all parties’ profitability, I can guarantee that it gets solved collaboratively in a more thoughtful manner. The initial phase involved a big-room, lean process by which the major decisions were flushed out very early and efficiently. This greatly reduced the overall design duration when compared with a more traditional delivery model. The major subcontractors had a role in the production of the documents, which resulted in greater buy-in on major decisions and MEP space planning. The architect, construction manager, trade partners, and engineers all share in the savings generated by this lean process. I am fully convinced that this process will get our project completed significantly faster and at a lesser cost than it would have under a traditional contracting method.
CSE: Is system integration increasing for medical facilities to enhance communication as building systems become more complex?
Hamilton: The technology that we are designing for the new health care environments is no longer a conglomeration of disparate systems but rather a complex mesh of integrated solutions, each providing data to the others. The building management systems talk to tracking systems that communicate with nurse call systems that are integrated to the electronic medical record and interactive patient systems. This results in a very complex system that requires more infrastructure and larger technology rooms.
Fuks: System integration is increasing. Various low-voltage systems within a medical facility are now being equipped with more computing power and, therefore, can provide valuable information to building systems. One example is lighting fixtures that already have occupancy and temperature sensors built in, which allows you to eliminate devices in the initial design. This saves first cost to the construction and provides for a more integrated utility network across the facility.
Harwell: The short answer is yes, but existing older facilities still struggle to make good use of this integration capability. Generations of older, proprietary, closed systems-and the older technicians that are used to them-often resist real integration onto a single platform.