Words by Katie Puckett
Flexibility is now the most valuable component of healthcare buildings
"Instead of ‘value engineering’ out everything that makes a project resilient, we should engineer in added value"Suzanne MacCormick, WSP
Facilitating the switch
In many places, the immediate response to this crisis was to provide surge capacity by converting large buildings such as stadiums or conference centres, or by constructing entirely new field hospitals from scratch. For the future, this strategy is shifting to provide extra capacity within hospitals themselves, or in very close proximity, so that they can more easily access the staff, equipment and infrastructure they need.
This time, the switch to “pandemic mode” has involved reconfiguring hospital entrances and layouts to separate infected and non-infected patients and associated flows of staff, equipment and consumables. Intensive care units (ICUs) were scaled up to care for a surge in critically ill patients, and isolation rooms improvised by installing fans and filters to create negative pressure. For the next time, greater flexibility in both spaces and systems can make the transition smoother and more effective. ICU rooms, for example, need a higher level of emergency power redundancy and a medical gas supply for patients on ventilators, and the hospital infrastructure has to be able to supply a much higher demand for oxygen.
“Converting normal patient rooms to ICU rooms is not plug-and-play,” says Gary Hamilton, healthcare practice leader at WSP, based in Washington DC. “You can’t just plug in all the equipment that’s required to keep the patient alive because the requirements are very different.” On one conversion project, he found that the medical gas system could be stretched a little – but that the hospital pipework wasn’t big enough to carry the higher loads. “We could have increased that during the design with a marginal effect on the whole infrastructure cost, and we wouldn’t have had a problem. But we weren’t designing for a pandemic. This is unprecedented, but it’s teaching us that instead of designing to the minimum the code allows, it’s important to take a flexible approach.” Other relatively minor design changes include installing an extra set of entry doors and extra fire doors between departments, to aid separation and compartmentalisation.
But exactly how far should we go? How much should owners and design teams try to anticipate the future, and what level of flexibility is it worth paying for today? Engineers already consider the interplay of emergencies from natural disasters to mass shootings, and the pandemic adds another layer on top. Raising code minimum could make the process easier, says April Woods, a vice president with WSP in Florida. She thinks the impact of COVID will be comparable to that of Hurricane Andrew, which devastated the state in 1992. “That changed a lot of the building codes here and up the coast, for all buildings and also very specifically the resilience of healthcare facilities. In the coming years, I think greater flexibility will just become a standard of care that we have to implement in all of our designs – for example, to allow the engineering systems to be quickly changed to accommodate a pandemic. When those become code-required elements, owners don’t have to decide whether to opt into something or not.”
"Converting normal patient rooms to ICU rooms is not plug-and-play. The requirements are very different"Gary Hamilton, WSP
"In South Africa, there is a long list of facilities that are inadequate or that needed additional capacity even before COVID-19, but there was no funding available"Jabulile Nhlapo, WSP
Into the unknown
Further into the future, advances in such diverse fields as telemedicine, wearables, genetics and artificial intelligence will mean hospitals need to accommodate new equipment for diagnostic testing and treatments, while shortening stays or making them unnecessary for all but the sickest patients. “Now hospitals are designed around the need for longer stays in high-acuity settings like ICU and med/surg,” says Nolan Rome, leader of WSP’s US healthcare practice. “But the baby boomers are going to be the next acute care generation, and we’ve never seen a patient population that has lived healthfully this long before. We don’t know what treatments they will need. Maybe those ICUs will be downgraded in acuity to become transition beds or short-term surg beds – or even exam bays because there is more day surgery.”
In a hospital context, it is neither desirable nor economical to equip spaces for any possible future use, especially given the increasing sophistication of medical equipment. Instead, we need to consider specific adaptation scenarios upfront and design for these. “We need to be very specific about the limitations of an area and exactly what it will be able to adapt to,” says Gunnar Linder, business area manager at WSP in Sweden and a specialist in engineering healthcare environments. In Gothenburg, WSP designed a highly specialist imaging facility with a modular, demountable facade. All of the operating theatres are located around the perimeter so that one side of each room can be completely opened up to replace the bulky equipment inside. The building systems can also be sealed off, says Linder, “so you can have a construction site within a fully operational ward”.
"We need to be very specific about the limitations of an area and exactly what it will be able to adapt to"Gunnar Linder, WSP
Target value delivery
In the light of COVID, and our heightened awareness of uncertainty, decisions that would have seemed counter-intuitive may become no-brainers. “We need to take more of a life-cycle analysis approach to resiliency decisions,” says Rome. “If a resiliency measure costs an extra 10%, does that 10% investment add value over the 50-year life cycle of the building?”
Healthcare owners rarely, if ever, sell their assets, Rome says, so they are in a good position to take a longer-term view. The US is a very competitive, cost-driven healthcare market, but providers are incentivized by government and insurance companies to reduce both length of stay and repeat visits. This has given them an added impetus to go beyond code minimum: “Most owners will do something if it’s a six-year payback or less. Anything in the seven-to-ten-year range, they will heavily consider if it helps to mitigate their risk, whether that’s infection risk or business case risk.”
"We need to take more of a life-cycle analysis approach to resiliency decisions. If a resiliency measure costs an extra 10%, does that 10% investment add value over the 50-year life cycle of the building?"Nolan Rome, WSP
WSP has been involved in several projects that take an innovative “target value delivery” approach, which breaks a project into component clusters and challenges the team to find efficiencies and added value for each cluster. This has led to greater innovation, such as prefabricated facades, but also enabled owners to clearly see where any savings from one area could be best invested in another. “If spending on flexibility or facilities can help them to reduce patient visits or operate at the same level with fewer facilities staff, then they’ll make that investment,” says Rome. “This system is helping us identify long-term resiliency paths, and really weigh and measure them so that they are accepted into the project as opposed to being value engineered out. You’re constantly doing that in real-time to make sure that you’re driving the value into your project.”
He thinks that this model also makes projects themselves more resilient. During the last market crash in 2007/08, many cash-constrained healthcare projects were put on hold for a year or more. “Now, these target value projects are weathering the storm with a little more surety and consistency because the owner understands where and why they’re spending their money. If they do have to make a reduction – because there have been three months of revenue lost due to COVID – we try to make it as shrewdly as possible and not affect the long-term outcome. If we cut something now, we may be spending twice as much money to put it back in six years from now when the building is finished.”
Target value delivery makes the case for flexibility even more compelling, and puts some numbers behind it. A hospital project may take six or seven years from design to completion, Rome points out. “Let’s say you saved 15%, if you wait until the very end to realise the savings, all you really did was lose the opportunity to invest that 15% over a six-year period. If you can bring that to the front and drive it into the value of your project, you’re using your money smarter. That’s a big investment when you’re operating on a margin below 5%.”
The built environment will always be playing catch-up in the wake of more dynamic systems. But digital technology is right at the forefront. In the next part of the series, we’ll consider how “smart” building solutions can help healthcare providers stay resilient in the face of change – and how to ensure the resilience of digital technologies themselves.