Many health facilities managers would like to be more successful in obtaining depreciation dollars to fund maintenance and infrastructure capital renewal adequately. Gaining access to depreciation funding often involves being more successful at selling the maintenance mission and requires a multifaceted approach.
The rules of engagement include such disparate approaches as communicating with budget committees and chief financial officers (CFOs) while employing the terminology they use for other hospital initiatives, wise use of empirical information to communicate salient facts regarding the hospital infrastructure, making sure to shift the risk of non-funding to those who make funding decisions, and fitting budget requests into the strategic big picture.
Facilities managers need to be able to produce and present sophisticated but brief financial analyses based on all of the facts relating to the facility infrastructure and risks associated with its condition.
Accessing data
An effective tool to help facilities managers prepare for and engage in budget negotiations is the amount of historical and current facility infrastructure data. This includes the total infrastructure asset inventory including the ages and condition of the physical plant's major equipment, useful life compared with actual years in service, availability or unavailability of spare parts due to obsolescence, past operational history and other considerations.
An overall database or even a simple spreadsheet matrix of major building infrastructure components with this information facilitates proactive management and analyses. In health care systems, putting infrastructure information on all member hospitals literally on the same page — either in a database or spreadsheet — also helps to make budget discussions more thorough.
It is often very helpful to relate specific components and systems to the areas that they serve, such as the operating rooms, critical care units, emergency department and imaging facilities. For example, obsolete and operationally problematic equipment — whether HVAC, medical gas, electrical or other systems — that serves major operating suites should be highlighted during budget discussions. It also can be helpful to provide photos or tours of existing infrastructure that is in poor condition or other weak links. Facility condition assessments are helpful in establishing the current infrastructure status. The results of these assessments can include equipment age, equipment failure histories and repair or replacement costs. Because many facility managers are hamstrung by ongoing under-budgeting that results in deferred maintenance, a master list of all deferred maintenance can be a useful tool in future budget discussions.
Infrastructure assets that are near or past their useful lives are a potential operational liability due to decreasing reliability. Facilities managers' opinions of useful lives, however accurate, may not be accepted by the hospital financial team. An authoritative resource regarding useful lives of facility infrastructure components used by many hospital financial professionals is the Estimated Useful Lives of Depreciable Hospital Assets, which is published by the American Hospital Association's Health Forum group.
Updated last year, the publication is described as "an approved reference for the assigned life of hospital and physician office health care assets" that has been an accepted Centers for Medicare & Medicaid Services reference. Facilities managers should consider obtaining this publication and using its information to reflect the estimated useful lives of their own facility infrastructure equipment. That information, including its tables on buildings and building components, can provide helpful backup during future infrastructure capital-renewal budget discussions.
Another area that is not covered often in capital-renewal budgeting and discussions is the results of critical system or critical equipment vulnerability analyses. A major mission statement topic of most organizations and also of many facilities departments relates to the quality of patient care and patient safety. An unreliable critical infrastructure system or component can have a major detrimental effect on both patient care quality and patient safety despite the best efforts of caregivers. Facilities managers should consider conducting vulnerability analyses of their own critical infrastructure systems and equipment so that the results can be considered prior to the next budget cycle.
Making the case
A health facilities manager should propose a separate facility infrastructure budget for annual capital expenditures that need to be considered separately from such areas as radiology, plus surgery equipment replacement and information technology expenditures. An argument in favor of this approach can be that the organization is financially depreciating its facilities and those depreciation dollars should be rolled back into the facility as much as possible to support the organization's mission. Facility infrastructure systems that are unreliable will quickly defeat the strongest cosmetic impressions.
Splitting budget requests into different categories often is a helpful approach, but the categories can be varied. Some organizations prefer to consider infrastructure capital-renewal requests categorized as jurisdictional (code or regulatory requirements), replacement (mission-critical systems and equipment that must be replaced immediately due to age, condition or concern about imminent failure) and cost-reduction (permitting direct comparison to profit centers). Other organizations prefer to consider capacity-related needs, categories that specifically address the organization's strategic plans, current hot-button topics or concerns, or simple categorization by infrastructure system type.
Utility operating budget preparation should take into account multiyear analyses that consider facility growth, changing fuel costs, weather normalization, previous demand-side energy conservation measures and other high-impact issues. Many facilities employ benchmarking comparisons in British thermal units per square foot, but it is important to take into account all related causative factors when comparing benchmarked data. Some organizations successfully have used energy utility demand-side funding grants to install demand-side management measures that offset higher energy costs while lowering overall energy use.
Both operational and capital renewal budget benchmarking literature and data are available from professional organizations such as the American Society for Healthcare Engineering, the International Facility Management Association and APPA, a similar organization for facilities managers in higher education.
Today's facilities managers no longer can rely upon simple payback analyses in most cases when discussing capital investment alternatives. It is necessary to communicate in effective financial language with the CFO and finance committee, using the types of analyses and terminology they use when considering new profit centers.
Facilities managers will find it helpful to present facilities costs in terms of the total cost of ownership. Total cost of ownership can include first costs, operations costs, maintenance costs, repair and replacement costs, energy/utility costs, space renovation costs, lost revenue costs due to failures and similar occurrences from not undertaking appropriate life-cycle activities such as preventive maintenance or predictive maintenance, lost-revenue costs due to other uncorrected vulnerabilities, occupancy and use costs, technology-realization costs, disaster-containment costs and contingency-planning costs.
Because effective supporting arguments for budget discussions often make use of revenue, cost, value or their combination, it will be necessary to use all of this information to identify the total cost of ownership.
Investing in flexibility
Infrastructure flexibility is important because the costs of operations, space renovations, relocations and ongoing asset resource items quickly exceed initial construction costs. Financial analysis tools that are helpful in presenting the total cost of ownership are return on investment, life-cycle cost, net present value, the internal rate of return, time value of money and fuel price fluctuations.
Many facility infrastructure upgrades will require multiple years to accomplish. Phasing the projects into smaller subprojects is an effective approach to reflect the realities of changing annual budgeting priorities. Some organizations often plan their major capital renewal projects with a three- to five-year moving window that splits major initiatives into two or more budget cycles. That way the more comprehensive picture is always in sight while each year's annual budget preparation and review are in process.
Facilities managers should be able to put together fact-based arguments as to whether the organization's 30- to 50-year-old buildings can support today's strategic medical initiatives. Many issues need to be considered in an analysis of physical obsolescence. With the building itself, floor plate limits and slab-to-slab height restrictions may negate the possibility of some strategic medical capital initiatives.
The existing mechanical and electrical infrastructure limitations may make needed electrical capacity, emergency power availability or reliability, mechanical operational reliability, sufficient air changes, proper pressure relationships or sufficient cooling impossible or infeasible without major infrastructure upgrades. Sufficient space and infrastructure for the needed IT systems and equipment, including modern video broadcast initiatives, may not be available in existing buildings. The space required and the infrastructure services needed for modern operating suites may not be economically feasible in existing buildings. The replace-or-renovate issues can be considered more completely when these and other issues are considered.
Moreover, infrastructure impacts can delay the installation or startup of new medical equipment without an early review and sufficient time for infrastructure upgrades.
Because new medical systems and equipment usually have an impact on both the IT infrastructure and the facilities infrastructure, many organizations ensure that the IT manager and the facilities manager are represented during the budget review process for new medical technology.
Consideration of new medical technology should take into account its impact on the remainder of the organization and its existing infrastructure; otherwise, the cost-benefit analyses for the new medical technology are inaccurate and can lead to wrong decisions. Both the information technology manager and the facility manager should sign off on all new capital equipment requests.
Because many members of the clinical community do not understand the different types of supporting system failures that can occur, it is also helpful to discuss critical operational needs during the medical equipment budgeting process to determine the cost of supporting infrastructure systems. For example, the impact of loss of power or cooling should be taken into account when determining the infrastructure for major new medical equipment installations.
It is wise for facilities managers to have at least two reasons to replace major infrastructure equipment or systems. Because new mechanical systems and equipment are often more efficient than much older systems and equipment, the facilities manager may be able to address several needs simultaneously in a budget discussion, such as fixing existing vulnerabilities, reducing energy costs and replacing obsolete equipment that no longer has spare parts available.
Risk of non-funding
Once these issues have been investigated, the facilities manager should be able to shift the risk of non-funding to the financial decision-makers. It is important that hospital administrators, including the CFO and other C-suite executives, clearly understand the impact of equipment and infrastructure obsolescence on the organization's business interests.
This doesn't simply mean age-related issues. All the items that make up the total cost of ownership should be unequivocally presented and understood. Facilities managers also should provide examples of the kinds of issues encountered when proactive infrastructure renewal is not funded, such as organizational impacts, higher costs and lost revenue due to a chiller failure in the summer or a boiler failure during the winter.
Even issues related to uncorrected vulnerabilities, such as the potential for an emergency power failure during a natural disaster, can be taken into account. The impact of such failures, including loss of revenue or prestige then can be understood as the business context of facility infrastructure financing needs.
The organization's business goals should be related to critical areas and functions which, in turn, should be related to the reliable performance of critical infrastructure systems and equipment. Then, the existing condition and recommended capital renewal can be put into the context of the organization's business goals. Once the business disruption issues are clearly understood, the organization can make educated decisions on business risk.
Finally, facilities managers need to use their volumes of information in a quick and concise manner, much like the "elevator speech" concept. It is helpful to be organized and present the main features of their needs as benefits to the organization in terms that listeners are interested in and responsible for. The closing should summarize and sell the funding request.
A persuasive case
As hospital administrators continue to keep a close eye on new spending, health facilities managers will find it more likely that their requests for needed infrastructure spending will be granted if they present a persuasive case.
David Stymiest, PE, CHFM, CHSP, FASHE, is a senior consultant for compliance and facilities management at Smith Seckman Reid Inc., Nashville, Tenn. He can be reached at DStymiest@SSR-inc.com.
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