The long-term benefits of good design
The integration of facility management into the design process is especially important when it comes to healthcare facilities. AIJA THOMAS, director at Silver Thomas Hanley, reveals the many benefits of this approach.
Winston Churchill was once quoted as saying, “We shape our buildings and afterwards our buildings shape us.” This may have been so in his day and continues to be so in many buildings today; however, it cannot be so in hospitals. Too much is at stake. If a hospital building is not functionally appropriate, then the costs associated with inefficiency are accrued 24 hours a day, 365 days a year. There is no shutdown period in a hospital and the complexity of clinical and non-clinical services is increasing.
The provision of healthcare services has undergone substantial changes over the past 20 years. The ageing population, developments in pharmaceutical treatments, new treatment modalities and greater consumer expectations have combined to create a greater demand from hospital services and healthcare facilities themselves.
Salaries and labour costs now approximate 70 percent of the annual recurrent costs in acute care hospitals. In Australia, there is a smaller salary band for operational staff; therefore, healthcare facilities must be designed not only for clinical efficiency, but also for all levels of facility management services.
The challenges facing both the healthcare provider and the facility manager in developing and maintaining viable, cost-effective facilities are complex and multidisciplinary. Strategic planning, viable data, lean principles and an effective, experienced design team that partners with the healthcare provider all play a significant role in ensuring a facility optimises all opportunities.
The consideration of facility management in healthcare facilities is paramount in maintaining staff safety and satisfaction, and ensuring better and more predictable patient outcomes. The role of the facility management provider is now more important than ever on the majority of projects, particularly those procured under the public-private partnership (PPP) procurement model, where they are a key member of the design team from project outset.
Integral to the design challenges is ensuring project and operational viability in both first capital cost and ongoing sustainability. Key to providing a viable project is to ensure:
- a feasibility based on health service provision, operation and financial viability, and facility design based on life cycling
- the healthcare provider has a strategic plan and vision based on viable and reliable data and forecasts
- an integrated design approach getting ‘buy in’ from the healthcare provider, the financier, the contractor and the design team is established, and
- process review, lean principles and challenge are undertaken of all phases of the design and commissioning process.
Historically, in most countries, maintenance of health facilities would be ‘deferred’ due to cash and political considerations and an environment of ‘Band Aid’ fixes and drip feed cash flow would be the norm. While this still occurs, the critical aspects of maintaining a health facility over the long-term cannot be underestimated in terms of the capital, operation and patient outcomes. A well-maintained facility has tangible positive outcomes in terms of patients, staff and visitors in a number of key areas in the context of the PPP procurement process.
PPP PROCUREMENT SMARTS
The PPP procurement method has been one of the most extensive changes to the design, construction and life cycling of healthcare facilities. Silver Thomas Hanley (STH) has been undertaking PPP projects for 15 years. During this period, we have seen this procurement process mature.
The greater role of the facility management provider and the development of key performance indicators relating to facility maintenance have enabled us, as architects, to take a longer-term view and implement design strategies that were considered prohibitive previously. Initial capital cost is no longer the primary driver; life cycle costs over the term of the concession are the key.
Based on our Latrobe Hospital experience, we were able to identify the ‘smarts’ and transfer these across to future PPP projects. The project was a BOOT (build own operate transfer) project constructing a new Greenfield hospital to combine the ageing Moe and Traralgon hospitals and it was undertaken in full consultation with Honeywell.
These smarts included:
- the ability to fast-track design
- simple building elements
- access for maintenance
- access for change
- centralising hotel services
- initial capital cost versus maintenance, and
- life cycle investment analysis.
We transferred these smarts across the Pacific to the Abbotsford Hospital in British Columbia, where we were part of PPP consortia, Access Health. We won the competitive bid and worked with Vancouver-based MCM Architects, PCL Contractors and Sodexo as the facility managers and ABN AMRO as the financiers. The project is a good example of FM integration into the design process.
LOW MAINTENANCE MATERIALS
The 60,000-square metre Abbotsford Regional Hospital and Cancer Centre provides Fraser Valley in British Columbia with a 300-bed replacement facility providing a wide range of services to patients, including an integrated cancer centre, a University-affiliated learning centre, promoting research, training and retention of health professionals and a patient-centred healing environment. The project has a concession period of 30 years.
With a design service life of 50 years, the life cycle value for capital expenditure was critical, including minimising both interior and exterior material replacement and/or maintenance. Cost consultants regularly reviewed costs of proposed material selections against criteria of long-term durability, ease of maintenance and replacement over time.
Considerable effort was expended in making caregiving efficient and productive. The facility is divided into six pods, each performing a different role – overnight stays, outpatients and diagnostics, for instance – but closely grouped around a central 24-metre high atrium, designed to provide a distinctive non-institutional feel. Moving from one pod to another is simple, reducing fatigue for those moving around and ensuring that care, diagnostics and treatment are delivered as productively as possible.
The atrium serves as a strong way-finding and environmental feature. The atrium is visible from virtually anywhere in the hospital, providing orientation to the required destination and back to the front entrance.
A key design highlight is the efficient and tightly integrated hospital layout for ease of access and staff/patient movement. It promotes staff efficiency by minimising travel time between frequently used spaces. Support services, public, emergency, staff and patient circulation are also well-separated.
Operationally, the facility now benefits from clearly designated and separately zoned accommodation for acute care, day procedures, cancer care, ambulatory care, mental health and support services. It has logical circulation patterns and clear way-finding. The service departments are in the centre of the design, thus minimising travelling distances.
Design principles of solar orientation and access, the air-conditioning plant design and building envelope thermal efficiency (using low e-glazing) resulted in 38 percent less energy with reduced recurrent costs of CA$480,000 per year compared to compliant designs. In addition, low-flush toilet fixtures reduced potable water use by 20 percent.
Connections to nature/areas of respite were included in the design and air quality was also recognised for its impact on the healing process and on workers’ productivity. We focused on reducing VOC levels and provided access to external gardens, as well as controllability of the zoned internal environment.
FULL ENGAGEMENT KEY
STH’s success in numerous PPP projects, including the new Royal Adelaide Hospital, Orange Hospital in New South Wales, Casey Hospital in Victoria and St Catherines Hospital in Niagara, Canada stems from our full engagement with the facility management providers from day one. This enables us to design the most effective and efficient facilities. It is a two-way relationship and the best outcome is when both parties are willing to engage fully from day one.