Approved! The project design is finally completed. After months of intense planning, consensus has been reached and the construction documents can now be implemented.
There’s just one major problem remaining: How to build it? You can’t just shut down the health care facility; it must remain open during construction. Treatments must continue without interruption; patient care cannot be compromised; and the project has to be built on-time and within budget. It’s a daunting task that faces every health care project that involves significant renovation of existing facilities.
Maintaining accessibility and procedural logistics are critical to the ongoing success of the organization. To do otherwise would negatively impact not only the facility’s viability, but the surrounding community that relies on its medical resources. Failure to function is not an option in the health care universe.
Details, details
A facility upgrade must proceed and the facility must adapt and work around this temporary disruption. This requires meticulous coordination. Missing one crucial detail can result in increased cost and frustrating delays.
To help health care facilities professionals navigate around this contradicting dilemma, the following 10 preparation points are outlined to assist in putting together a comprehensive phasing plan.
1. Identify critical dominoes If a project will involve large-scale renovation and expansion of strategic departments like emergency, oncology, critical care, surgery and diagnostic imaging, then how it will be implemented must be on the agenda from day one. How will the existing areas that remain in operation be accessed? How will the new construction be accommodated? Build the addition first, then start shifting the functions? Or relocate spaces out to gain the necessary buildable zone? What’s the correct sequence? Getting the staff involved early in these decisions is very important for their buy-in and facilitation.
For example, for the emergency department expansion at Regional Medical Center in Memphis, Tenn., the new construction is being built first, then there will be three major renovation phases to transform the old ED area. The existing treatment spaces will be kept up and running during much of the project. Then, the staff will open a transitional door and enter their new state-of-the-art facility.
2. Maintain Site logistics If parking areas are removed and alternate entrances required, who goes where and what interim accommodations are needed? Should a temporary canopy for the ER ambulances or the main entry be built? Will service trucks have to change their delivery schedules? How about signage? Invite the EMS and Stat Flight crews to a meeting to discuss the proposed circulation and additional steps to implement.
To permit a $20 million expansion/renovation project for University Hospital in Louisville, Ky., for instance, the first domino was the creation of a temporary helipad. This allowed a tower crane to be positioned near the existing helipad. Without this seemingly minor detail, the project could not begin.
Similarly, for an ambulatory surgery expansion project at Hardin Memorial Hospital in Elizabethtown, Ky., several different parking arrangements had to be coordinated and a temporary loading dock built.
3. Assess Engineering challenges Perhaps the most complicated process is figuring out how to keep all the MEP infrastructure elements and systems properly working. The existing spaces must remain operational during a project. To do so, current mechanical ducts, electrical connections and plumbing pipes have to be prioritized and protected or rerouted.
On one hospital project, an early phase required demolishing a section of ductwork. However, the ductwork supplied an area that was to remain for several more phases. Another oversight that is typical in many construction projects is removing power panels that serve areas outside the project scope of work. Due diligence when conducting infrastructure assessments is paramount to preventing these nightmares.
4. Keep delivery dates in mind Prior to permitting the contractor to start demolition, be sure all the long-lead items are ordered and no delivery problems are anticipated. A late-arriving air handling unit or a backlogged steel shipment can create a chain reaction for the entire effort.
The concept of building information modeling (BIM) is starting to make an impact on this section of phasing. One Denver-based construction firm put together its own illustrated 3-D sequence diagram that detailed how the work was to be phased on a weekly basis. Each subcontractor was then provided with this diagram. Consequently, they knew exactly what was required and when. Such real-life illustrations are a great benefit to the overall effort.
Sometimes, a text description or bar chart is difficult to interpret. But floor plans that highlight the transitions and changes can emphasize that the casework must be installed by a certain date or that demolition of the old electrical closet is a critical path item that could hold up the entire project if not done on schedule.
5. Plan for Interim life safety While the final plan will comply with all the building code requirements, the interim phasing may not. Dead end corridors, wrong exit light directions, missing fire extinguishers and other potential hazards must be addressed. Temporary egress passages and fire doors may need to be installed. Partition barriers are to be built with fire-rated materials.
Having the fire marshal conduct a walk-through prior to phasing implementation is suggested. On many projects, this type of on-site safety review improves the interim egress routes and heads off potential code violations.
The installation of large and small pieces of medical and office equipment is fraught with challenges. For example, many facilities seek to relocate existing equipment such as copiers and monitors. However, such reuse requires careful review. Equipment such as radiographic units, sterilizers and surgical lights cannot simply be moved overnight. It may take a few days or weeks. And this equipment will not be usable for the existing treatment areas during the move. Often, what started out as a way to save money turns into an expensive miscalculation.
7. Minimize phases Every phase lengthens the schedule and adds more costs. If the team can complete the project in three phases instead of five, they’ve just saved a lot of time and expense. Maybe a mobile CT scanner can be leased to allow renovation of the existing CT scanning space. Or maybe the staff can sacrifice their lounge, offices and other nonpatient support rooms for a few months to expedite construction. Being creative in phasing planning will pay dividends throughout the course of the project.
For example, during a “second-look” review of one hospital project, a team member questioned why a diagnostic imaging expansion had 12 phases. This seemed like an overly high number for one department, even though it had numerous procedural rooms. Once the staff was consulted on how these numerous phases would drag out the project, they agreed to several compromises that reduced the project to five phases.
Keeping the positive end-result in mind will lessen the negative inconveniences of this process.
8. Maintain Contractor access How will the construction workers and materials enter and depart each phased zone? Will there be any overlap with patients, staff and visitors? Will the construction need to be performed at night and/or weekends? These types of questions must all be considered and unconventional solutions can sometimes prove to be the most effective.
For example, one large urban academic medical center needed two construction elevators to facilitate their interior phasing sequences. The project was to last several years and to lease these elevators would be fairly expensive. So, it purchased this equipment for contractor use. The elevators were moved around the exterior as the different phases were transitioned, and it provided an exceptional solution to a challenging accessibility nightmare. This not only saved thousands of dollars, it prevented materials and subcontractors from being in the hospital’s main elevators.
9. Remember to protect the surrounding clinical environment While hammering and sawing takes place within the phased zone, quality patient care is being provided on the outside. To minimize any potential disruptions, preparations must be arranged to mitigate any negative issues relating to infection control and construction noise and vibration.
Establish the protocol for workers who will need to venture out into the treatment spaces. How will the facility be notified and what will be the safeguards? Not only should the areas immediately adjacent to the work area be evaluated, but also the functions above and below it. Especially sensitive areas such as oncology will need to be properly addressed prior to implementation.
At the Regional Medical Center in Madisonville, Ky., for example, the labor and delivery unit was relocated to another patient floor. A temporary delivery and C-section room was built, as well as a nursery. Then, the old spaces were renovated in sections. As each zone was completed, patient care was relocated. An existing elevator was dedicated to construction use and barrier partitions were used to control the environment.
10. Put it in writing Finally, a project team may have discussed all of the above steps, but it could still fail. “If it isn’t written down, it doesn’t exist” is especially true for phased construction projects. The specifications and construction drawings have to very clearly spell out how the contractor will perform the work.
Any unique methods (i.e., temporary canopies and interim egress passageways) also must be defined up front during the pricing process.
All designers have horror stories of the eye surgeon calling the CEO demanding that the jackhammering in the hospital be stopped immediately. Or patient complaints of noise and strange smells in the facility. Discussing the step-by-step procedures beforehand with the staff will avoid unwanted consequences later. Also, expect change orders if the work procedures have to be established or altered after the contract is signed.
Best end result
Multifaceted phased health care construction involves numerous meetings and analysis sessions. During these sometimes endless gatherings, remember that phasing inconveniences are only temporary and the final floor plan will last for decades.
The best end result takes priority over an interim arrangement. If performed in an organized logistical sequence, phasing should not have a detrimental impact on the facility’s ongoing functions and should have a positive impact on the health care organization’s long-term goals.
Then, at the ribbon-cutting ceremony, when all the construction hassles are a memory, the hospital staff can start thinking about the next project! n
Steve Wiser, AIA, is the director of health care design with JRA Architects in Louisville, Ky., and author of No Surprises! Minimizing Change Orders in Hospital Construction. He can be contacted at wiser@jrarchitects.com.
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