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Facility Management and the Design of Victorian Public Hospitals

Ben Gelnay Capital Management Branch Department of Human Services 7th floor, 589 Collins Street Melbourne VIC 3000 Australia

Abstract: It is the thesis of this paper that discipline of asset & facility management has not been given sufficient opportunity to participate in determining a hospital's capacity to deliver services and the involvement of FM is critical in the early planning and design phases. This requires a change to the thinking of planners, architects, engineers etc. from stages such as functional briefing and master planning. A close link between FM and the design disciplines will assist in the development of concepts, assessment of impacts on facilities’ operations and associated recurrent costs.

Keywords: Hospital design, facility management

Emerging Challenges

The design of a hospital and its supporting infrastructure has a major influence on the delivery of health services. The design phase is crucial in determining the facility's capital cost and operating efficiency. How are people receiving the design to if they are getting a hospital that is fit, safe and sustainable?

Experienced professionals from the private sector are employed to design or reconfigure hospitals. Generic briefs, standards and guidelines*1 have been developed to help, however hospital design processes relies on the skill of architects, engineers and cost planners to translate users’ needs and functional requirements into built form concepts estimates and construction documents. These documents describe the form and manner of the outcome in terms of fit for purpose, robustness, durability, flexibility, compliance and ease of operation.

The hospital designs are normally presented to the client for acceptance at several stages (See Attachment 1) in order to ensure the proposed works meet the requirements and here in lies a challenge. How can people knowledgeable in provision of medical care come to grips with the meaning and implications of a bunch of lines, drawings and words when the outcome is difficult to predict? Translating reports to built form is as hard to visualize as interpreting a dream.

Consultants are in the business of selling ideas. The consultant’s most important audience is the board of management and senior hospital executives. The importance of design to these clients can be measured in terms of how much

Proceedings of the CIB W070 2002 Global Symposium Copyright © 2002 by CIB and CABER 526 attention and energy is directed to the creation of images, designs, perspectives and models.

Design consultants are specialists in disciplines associated with the front end of projects and often have little or no appreciation of the difficulties associated with daily operations, maintenance, recurrent cost and related asset management*2 concerns. This is a challenge that designers must strive to overcome.

The lack of workable designs that allow for ease of maintenance or introducing changed operating regimes to be introduced is testimony to the inflexible schemes developed through all planning stages. Scant attention is given to longevity of replacement items or doing routine maintenance without disturbing theatre operations and day-to-day functions such as replacing lights and cleaning filters etc...

A hospital can continue to function with very rudimentary facilities; surgeons can even operate in a tent if they have access to basics such as potable water and electricity to perform surgery.

Yet the disciplines associated with the ongoing provision of these engineering utilities are virtually invisible in the design process. Whilst the Facility Management sector (FM) is responsible for hospitals’ energy, communications, environmental, safety and emergency systems, FM has not yet achieved recognition or prominence to influence the design of health services

Designers often relegate those involved in sustaining maintenance and operations to an incidental or marginal role. FM is seen as a discipline dealing with cleaning contracts, preparing purchase orders for minor works or helping out when the hospital is seeking accreditation.

The third challenge is to encourage design professionals to bring FM into the design process when assessing risks, dealing with business continuity threats and putting in place contingency arrangements. FM advice regarding functionality fitness and safety is seldom sought and becomes evident as it is often at the time that an emergency such as an electrical grid outage coupled together with back up generator failures that the problems are recognized.

At what stages should designers and FM interact? Discussing risks are best begun at early steps in the planning process as shown (See Attachment 1). Designers can use FM insights and guidance to identify key elements dealing with emergency and disaster planning.

Summing up the challenges, the value that FM can bring to the design process can be identified as critical in key areas such as:

• Preparing Briefs and Performance Benchmarks. • Formulating Facility & Building Services Design. • Review Expenditures and Capital v Operating Costs. • Undertaking Risk Management & assessing Contingent Liability.

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Commissioning programs and working within the unique cultures of hospitals and the building industry are also important areas where the design and FM disciplines overlap.

The Brief

Where should we start? What should the brief contain? Who should be involved in preparing it? It is not easy to make a design robust when requirements are vague, inconsistent or ill defined. There may be no documented hospital brief or the brief may not have been through an approval process. The brief may be based on invalid assumptions, preconceived outcomes; lack clarity and/or fail to distinguish between demands and needs.

Successful projects require a good team working on a clear vision with a knowledgeable client. Starting at the briefing stage, including FM is necessary for the client becoming an “informed consumer” with a well-prepared brief. The client hospital has many roles from user, operator and provider etc. and allowing for FM input to the design brief will assist in setting performance targets for accommodation, flexibility, durability and reliability. The brief also includes criteria for the purposes of selection and FM can be most useful in setting such criteria so that the best consultants/contractors are selected. In turn the designer, by responding to such a brief, will be provided with the best opportunity to meet the client’s requirements.

The brief preparation process should provide for FM to determine:

• How the building could be used and allowing health services to continue while works are underway. • Identifying potential problems associated with practical issues such as accessibility or security. • Providing for flexibility or expansion at the early design stage that may be negligible in terms of costs for a substantially beneficial outcome. • Identifying resources needed to operate and maintain assets.

The aim of providing FM input to the design brief is to bring value to a capital project by way of less maintenance and operating costs. Too often technology is ‘smeared’ around the building and ends up taxing the brains and resources of the occupants and operators.

Buildings systems may be tweaked up to operate satisfactorily. By understanding how the underlying systems work and the design capabilities of engineering systems, FM can obtain better performance and exploit the full potential of building’s performance capacity. It may be simple yet effective as small changes at the conceptual stage are as easy as the stroke of a pen without impacting capital costs. The consequential impact on resources, staffing and associated costs can be huge.

If the design brief is set by FM then solutions will be sought to issues such as minimizing the length of perimeter wall, maximizing natural light penetration into buildings or overcoming circulation systems conflicts such as the delivery of produce and the removal of infectious waste.

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Issues that need to be raised in regard to a project brief are:

• How is the facility to be managed following handover? • What is in place to link funding approvals to operations? • What are the performance criteria to be used to determine the operational viability of a new or refurbished facility? • If the life of building services were changed how would this affect the design? • Should a payback period of less than 3 or 5 years be justification to approve additional capital expenditure? • Will the building and services easily be modified or do they require major change to plant and infrastructure? • What are the recurrent costs associated with operating a new or refurbished facility and how does this compare to present costs or other similar projects?

The commercial sector provide examples of how facilities can best satisfy internal and external customer needs, support innovation, improve responsiveness and ‘cycle times’ in response to the changing business environment, reduce the cost of a product or service, reduce levels of risk and improve reliability – so why not hospitals?

A brief that recognizes needs that arise over the long term, accommodates users’ requirements in a practical manner and sets down requirements is needed before people can tackle the language of plans, technical drawings and specifications. Needs described in this way can be discussed and priorities determined.

Undertaking post occupancy evaluations can assess the success of a hospital project by comparing the result with the initial brief. FM who is familiar with the facility is best suited to testing compliance with the brief.

Benchmarking

Performance criteria and benchmarks are beacons for designers - they are of use when preparing briefs, assessing plans and to compare proposals with hospitals that have been found to operate efficiently. The difficulties associated with establishing benchmarks arise because of insufficient relevant data and the lack of definition for standards terms. However FM is in a prime position to clarify hospital needs for redundancy, flexibility and reliability and translate these into quantities for the designer.

The benchmarks used in the Victorian public hospital sector include physical characteristics such as ward and theatre sizes, financial characteristics relating to costs / square meter and functional characteristics such as number of operations per theatre.. There have been different benchmarks applied for new and refurbished facilities and the department has confirmed the benchmarks by undertaking post- occupancy evaluations and functional reviews.

DHS is now seeking to establish even better ways of measuring performance requirements such as life cycle, and recurrent aspects. Examples of this are measuring consumables such as area, energy or capital costs to support services

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 529 delivered. Facility managers are often in the best position to ascertain performance measures because of their familiarity with facilities operation and maintenance.

The key responsibility of FM when dealing with designers of new or redeveloped facilities is to set the performance criteria for engineering and building services. This then forms the basic framework for an “Asset Management Plan” that is a requirement of government policy on Asset Management*2 including the establishing an asset register, undertaking condition assessments and maintaining essential service records.

Issues such as the lack of standard terms, increasingly complex-engineering considerations, changing models of service delivery and technological changes can influence the method of operating and maintaining hospitals. The use of benchmarks and maintaining of historical databases are methods to establish better outcomes that are long overdue.

The key performance indicators used to measure and monitor facility suitability need to be derived from discussions with users and management to give the organization design objectives based on an integrated view of the facility as a whole. FM can do this task rather than relying on poorly documented needs that overlook a goods and materials management system that meets the needs of engineering, accounting, nursing, cleaning, disposal, security and safety.

Hospitals are comprised of functional areas that vary in terms of physical and economical life. It is important to appreciate the differences in functional areas at the design stage when evaluating the differences between redevelopment and building of a new facility. The DHS has undertaken studies of functional areas for the purposes of benchmarking facilities across the state of Victoria. Functional areas can then be benchmarked against other facilities e.g. hospital administration and office areas can be compared with their counterparts in the commercial sector as can kitchens, laundries and engineering *4. The cost of construction and expected life, period between major refurbishment has been benchmarked by the department, and is now used by hospitals to compare the plans produced by designers. Until recently this has been directed to area and cost and more recently has been extended to energy use and maintenance cost

There are several areas that are unique to hospitals, such as wards and treatment areas. In these areas the benchmarks and performance indicators are considered to be unique to the hospital sector. The department has found that in these circumstances benchmarks may be more applicable between hospitals with the same classification, e.g. tertiary teaching facility, metropolitan or regional based hospital.

The following Table 1 sets out the key performance indicators for use in the design of new acute health facilities.

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 530

BENCHMARK UNIT Facility energy cost ($/m2) $19.60 Facility energy efficiency (GJ/m2) 1.32 Gj Hospital services energy consumption ($/unit) $39.26 Hospital services facility utilization (unit/m2) 0.61 Facility income efficiency ($/m2) $2.42 Capital utilization (%) 69.42% Facility management ratio (%) 4.00%

Table 1: Benchmark values of the Key Performance Indicators

Facility energy consumption and costs are now required to be produced by the design team at the schematic plan stage and annual management expenditure can be compared to budgets so the overall cost of managing and maintaining can be established for the hospital and its component parts.

Facilities Design Stages

What are Critical Success factors to bringing about a successful hospital design? Complying with accreditation, policies and regulations to mention a few items. However, it is possible to bring better value to the hospital at the design stage by bringing the right expertise to bear at the outset (See Attachment 3). The opportunity to maximise value and minimise waste at early design stages via access to FM knowledge and focus on through-life issues so as to minimize the total cost of service delivery. The most important costs are service related with efficiency, absenteeism, interruption and churn being of most concern. The facility manager can assist in the process by providing critical knowledge and expertise.

Important decisions taken at the design stage that will have a significant impact on the hospital recurrent costs for years to come need careful consideration including:

• Building footprint, rehabilitation, height and mass of the building mass • Selection of structural systems, equipment, and cladding materials • Flexibility and ability to operate areas independently. • Selection of communications, services, energy & security Systems technology.

A design maxim stipulates that the biggest savings can be most easily achieved at the early stages of design. As documentation becomes more developed, and designs become refined and fixed, changes are more difficult to introduce. Accordingly there is greater resistance and less ability to achieving lower recurrent costs. There are fewer opportunities to examine areas of impact on capital and recurrent budgets. Approvals and commitment to designs become entrenched and links between architect, mechanical and electrical, structural, and civil engineers are more complete and detailed.

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 531

The outcome of recognizing the role of FM in addressing recurrent issues during the design phase will help ensure that increased reliability, lower recurrent operational costs and reduced replacement requirements will lead to better service delivery.

Redevelopment Versus Greenfield Solutions

Redevelopment of existing hospitals is far more frequent than development of new facilities. Designers overlook the fact that this typically occurs every 5 to 8 years for a regional base or metropolitan hospital. These upgrades, fit outs and refurbishments are well understood by FM who have to deal with these demands on a regular basis.

The rule of thumb that is used is that if the cost of refurbishing a facility is 65% of a new building or more, then the likelihood is that a new facility may be better option to pursue.

If the refurbishment of existing infrastructure were taken into account using normal discounted cash flow techniques, then the value of initial capital cost component would be greatly reduced. The impact of retaining existing facilities and the inherent continent liabilities these buildings and services represent would be explicit. FM is in a good position to provide realistic advice of how extensive these costs are and the areas that can be affected. Unfortunately, the bulk of our allocations continue to be drawn to areas of replacing existing infrastructure.

Strategic issues for existing refurburbishment:that are well understood by FM

• Ability to determine facility life cycles & consider in the design • Ensure compliance with statutory obligations • Review inclusion of deferred maintenance • Determine future expansion of the facility • Consider operating budget in the design

New site strategy issues for FM include

• Selection of appropriate equipment and services for the installation • Provide practical advice on simple no cost specification changes that provide measurable benefits to the maintenance of the built facility • Implement an asset management system at the construction stage of the project • Install systems at the outset that facilitate outstanding monitoring and controlling of operations

How often is it that we look back with regret on a redevelopment project that has been undertaken at great cost? That cost is often found to be within a few dollars of a new facility that could have been provided with new infrastructure, plant & equipment. If FM were involved the choice would be subject to far greater scrutiny and may have led to lower contingent liabilities associated with obsolete and dilapidated reticulation systems, engineering plant and dysfunctional buildings.

Refurbishment of hospitals is a time honored design activity that needs to be scrutinized much more carefully and recognized for what it really is – a compromise

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 532 to achieve some functional benefits that often carries a host of long term problems and financial penalties.

FM will bring a level of reality to the consideration of redevelopment versus new construction debate. They can do this by raising practical issues to be considered before adding another refurbishment and additional square meters to what are obsolete and dysfunctional areas supported by exhausted and decrepit infrastructure services.

Building Services

The building services in a modern hospital including mechanical and electrical systems represent more than half of the capital cost, or replacement value, of a facility. Building services’ designers specifically deal with the area of mechanical and electrical systems. FM expands this view to a wider vista and seeks to focus on the mechanical and electrical systems that compared to the building structural elements they have short life cycles.

The importance of major Infrastructure design in terms of accessibility, spare parts and servicing availability is often not given sufficient consideration by the design team. Too often maintaining hospital functions during routine maintenance, providing appropriate redundancy and spare capacity as well as reducing average time and frequency of failures are not adequately addressed in major health facilities building services’ design.

These same services account for the majority of ongoing non-clinical costs although they often have shortest life span of the building components such as foundations, structure or cladding.

Contingencies Fees PrelimsSubstructure 4% 6% 8% 6%

Services Structure 38% 26% Fittings Finishes 5% 7%

Diagram: Cost Plan composition for a typical hospital project

The design of building services is often devolved to technically competent persons who are rarely interrogated closely at the time of their engagement or at the time the concepts are being formed FM asks the difficult questions to get solutions that are

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 533 closely aligned to reliability, redundancy and lower recurrent operational costs and reduced replacement requirements that will ultimately lead to better service delivery. The impact that service interruptions have on staff effectiveness and the consequential delays and costs associated with carrying out procedures are never taken into consideration when the assessment of building services systems is carried out.

Value Management

The approval of funding of Victorian public hospitals capital works requires a formal value management (VM) exercise be undertaken for all key stages of projects exceeding $5 million. The VM process is to assess the viability of proposals and to be assured the key design objectives have been met appropriately. The VM can raise issues for action, to determine if sufficient consideration has been given to alternative methods of achieving the required outcome or possibly to identify if there are better/cheaper ways of reaching the desired outcomes e.g. does the design accord with the principles of sustainability.

However the use of FM expertise in VM or similar reviews is often inhibited due to the views of the design professions, project managers or even the management of the agency itself. There is a need to recognize the skill base that exists and obtain feedback from FM who has experience without inhibiting the opportunities to be innovative and develop alternative methods of solving design and development problems.

The assumption is often made that the user groups reflect the operational requirements of the facility. This assumption is unproven, and can be incorrect or qualified to the extent that user group inputs must be restricted. It is often decisions made at the design/documentation stage that preclude efficient operations or even lead to replacement of or reconfiguration of various pieces of plant, equipment or controls.

Close scrutiny of potential problems or possible costly variations are matters often more easily identified by FM than designers and may build confidence into investment decisions to avert future difficulties. Some aspects to be examined include:

• Target budgets for operation and maintenance energy and cleaning requirements • Capital funding for replacement - life cycles of major elements of plant and reticulation systems • Building automated systems, monitoring, control & risk management systems

Administrators, financiers and managers are increasingly concerned about value for money. Price is just one element of value. Assessing value over time is a challenge to old conventions with a view to achieving the best match of customer expectations and available funds. This assessment often requires skills and knowledge of the FM sector so that designers can exploit the opportunities that are available.

Estimating the initial, recurrent and replacement costs of operating the hospital under differing regimes is a requirement to achieving a selection based on full

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 534 understanding of life cycle costs. This may require background and recurrent records held by FM. Unfortunately the design teams’ knowledge and attention can become fixed on capital implementation issues rather than what happens afterwards

Expenditure - Capital Versus Operational

A major challenge that continues to face hospitals is finding funding. Competition for capital works funds has always been intense but in today’s environment this pressure is even fiercer. It is clearly important to manage capital costs during the design and construction phases. However as a consequence of the competition to obtain funds, a culture of minimising costs at the early stages of design has arisen. This can lead to solutions that offer short-term savings.

Where are recurrent facility costs going? There appears to be little empirical data or practical research about the failure to accurately forecast recurrent costs for new or refurbished facilities when design are prepared. Anecdotal information suggests the trend is for recurrent costs to increase exponentially when moving into new premises. Records show that cost/m2 can by up to 300% in various functional areas of the hospital.

A host of contributing factors drives the recurrent costs of a hospital. These costs can depend on matters such as demand for higher levels of comfort control, greater intensity of use (throughput & operating hours), condition, capacity, occupancy rates (of beds), number & type of pieces of equipment. There are benefits in having FM contribute to the work by the design professionals to predict the cost of the proposed works and how to assess the trade off between various items of equipment when maintenance is taken into considerations.

There is no agreed conformity between hospitals within a region, State or nationally included in maintenance expenditure. The elements that are typical areas of inconsistency include laundries, photocopying, vehicles, MATV, medical equipment. Furthermore, in some hospitals there appear to be one record kept by the accountancy department and another by the engineering department. There is no assurance that their records correspond.

When the hospital is being designed, reports include cost information such as estimates of construction costs and cash flows. These capital works cost plans are expected to be accurate to around 10-15%. However these cost plans normally provide construction estimates only at the master plan, feasibility, schematic design and the tender stage.

If the link between facility management and design were well established the cost information would include projected operating & maintenance costs and compare them with previous projections. In Victoria the formal approvals for project commences with initial allocation being set out in the state budget. The supporting document, the Investment Evaluation is the means to put up a proposal for funding to the Treasury boffins. FM can assist the design team in calculating of total facility investment over time by input into recurrent operating costs.

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 535

Too often when capital cost reductions are required as part of the design process it is the facility management area that suffers the most. Therefore what is needed to change the approach to the design process in order to achieve better outcomes? In answer to this query, the following issues need consideration:

• Cost planning focus is still concentrated on construction rather than operation. • New or redeveloped hospitals are costlier to run than the older facilities. • The healthcare funding sector demands greater benefits, more efficiency and reduced waste from new technology, flexible facilities and new work practices. • Clients have higher expectations and seek better quality services • More rigor and alternative solutions are sought from consultants and contractors as well as seeking competitive tendering of services. • Governments have sought private sector participation in the delivery of facilities to defer the burden of costs and transfer risks in capital works projects. • The private sector is seeking to provide services and facilities to complete service/building/finance/operations. . Payback periods for additional capital costs has long been recognized as providing a justifiable case to increase in the capital budget for example by bringing forward recurrent cost savings to fund better outcomes or seeking 3rd party financing in order to provide facilities that meet long term objectives*5.

The inclusion of FM in selecting the appropriate procurement model for hospitals is unconventional. Facility managers are not usually involved in selection of services or equipment and rarely consulted when choosing between contracting and financing options such as Design and Construct, Build and Maintain, Construction Management or Performance Contracts. This exclusion denies the sharing of experience or critical considerations when establishing selection criteria, identifying benefits and liabilities and setting out terms and conditions to mitigate risks. The role of the FM should be considered when selecting a procurement method and the consideration of pros and cons when different methods are being evaluated.

Business Continuity

FM can contribute to the design of hospitals capacity to meet their operational robustness by identification of risks, critical points of failure and exploring means to overcome these potential failure areas. It is often difficult for the originator of a design or solution to a problem to assess the outcomes that may arise from a multitude of different scenarios. The ability of the facility to continue working the delivery of critical utilities (electricity, water etc) may need to be provided in unconventional ways not considered by the original designer, especially after the facility has been functioning for a period during which modifications and additional requirements have occurred.

There is a need to have a practical knowledge of what aspects are likely to arise in various scenarios such as failure of various systems simultaneously – e.g. the communications systems could fail at the same time as the electricity outage occurs.

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The FM is in a position to propose/consider the scenarios of how the facility is to be used in emergencies to appropriately manage its operation when the unforeseen occurs. It is necessary to find different ways of maintaining the business of health care in a range of situations even at the design stage. It is also useful for designers if facility managers reconstruct previous incidents in planning for future incidents and in streamlining any issues related to liability or insurance.

Facility managers are often the best placed to advise designers on business, human, building and regulatory components in matters associated with essential services such as:

• Preventative actions to reduce the chances of an emergency occurring through initial design including surety and reliability • Detection and notification requirements • Responding to long-term outages and multiple events. • Provision of backup systems in the event the primary system breaks down. • Evacuation and decanting needs e.g. identifying decanting areas. • Control and mitigation measures involving human intervention e.g. firefighters and staff.

Contingent Liability

The term ‘contingent liability’ has yet to find a place in today’s designers’ vocabulary. There is a need to involve the design team in understanding the range or risks associated with facilities and their management in the early design and cost planning stages. FM can assist especially during the conceptual and design stages by providing input into the identification and mitigation of risks for all parts of the hospital.

Objectives such as being fit-for-purpose and safe facilities have been set out in a variety of regulations such as the Building Code, Fire Risk Management, Legionella Risk Management, OHS requirements, statutory requirements of the Electrical and Plumbing Commissions, the department’s Capital Development Guidelines and Essential Services Regulations. Often various regulatory areas have conflicting requirements that cannot be resolved simply by “design” but need the practical views of the hospital FM to resolve and prioritise how operational matters can be dealt with.

For example, in dealing with the emergency services and authorities (Fire, SES, police etc) as well as the hospital administration and culture of the organisation, FM are well placed to comment or even direct the solution to matters such as principal points of access, control of precincts, isolation of services or areas and/or establishing alternative control regimes.

The bulk of capital work in the health sector today involves the redevelopment of existing facilities. It is clear that the risks associated with existing major plant and reticulation systems are very important and need greater consideration when planning projects because of the level of complexity when overworked and obsolete infrastructure is utilized. Typically these issues are never fully funded when new additions are built and may lead to disastrous outcomes if these essential service systems fail.

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The hospital board, CEO or chief finance officer can appreciate an asset represents an increasing drain on resources. Budgets for operating and maintaining a hospital are now viewed as ballooning costs that provide little by way of increased return. Too often the estimated recurrent costs associated with new or refurbished hospital designs have been considered superficially at the design stage rather than becoming the platform for a serious forward look.

Buildings and infrastructure become a liability from the day they commence operation. Facilities represent both a resource and a liability and accordingly they are an amalgamation of benefits and risks with impacts that include contingent liabilities that have:

• High likelihood and high impact such as technological changes and increased community expectation & statutory regulations. • Low likelihood but high impact such as war, environmental disasters, accidents and sabotage. • Low impact such as changes in tenure, methods of procurement and corporate structure.

Risks termed contingencies are reflected in the project budgets. Allocations in new construction are generally 30-40% less than for refurbished projects based on experiences with difficulties in dealing with existing conditions such as asbestos, demolition, working in functioning facilities and poorly documented engineering services. Elements that need to be considered in the assessment of contingency requirements are set out below.

ELEMENT Cost of Operating Life cycle Recurrent provision Cost Impact * Land High Low Long Negligible Decanting Medium Low Short Negligible Fees & Charges Low Low Short Negligible Substructure Low Low Long Negligible Structure Medium Low Long Medium Cladding Medium Low Long Medium Fitouts Medium Medium Medium Significant Building Services High High Medium Most significant Site works Low Low Long Medium Commissioning Low High Short Significant

Table: Hospital contingency elements

* The recurrent impacts are considered only for non-clinical sectors.

When project estimates are found to be too high, cost reduction activities come into play such as reducing quality or contingencies for a project. While the net effect of these actions is to reduce costs, it may involve shifting of risk with undesirable long term consequences. What of these and other contingent liability risks that can be managed by good planning and design? Over the past several years, a number of disasters have occurred across the nation. Earthquakes, gas and electricity outages,

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 538 contamination of water supply, fires, workplace shootings, and vandalism have all grabbed headlines. These events have led to an increased focus on being prepared for emergencies with a contingency plan.

FM is best placed to ensure best service delivery outcomes can be maintained by engaging with designers at the concept and design stage to ensure consideration is given to contingency planning. The arrangements to be built into the facility’s structure and fabric to make sure robustness and the ability to remain operational under a variety of circumstances are fully examined. .

In order to deal with contingent liabilities and derive most benefit from the opportunities available at the design phases, it is necessary persons familiar with managing facilities to consider

• Environmental concerns • Maintaining essential service requirements • Maximizing reliability • Obtaining low energy costs • Providing for a healthier lifestyle

The facility management budgets may represent only a portion within a total hospital budget but its impact far outweighs the relative amount. Without electricity and potable water, nurses and doctors would be left with little to do. It is then puzzling how little consideration is given to facility management factors regarding risks associated with these elements when considering building service systems, material selection and equipment specification. When preparing designs for a new or refurbished facility the design team should report to the client on cost contingencies and liability factors including those set out above.

Commissioning

There are several commissioning processes that take place including the building procedures to get all physical facilities working as per the designs and another process involving he future occupants of the facility to become familiar with the day- to-day operations. FM should be involved in the planning of both processes and in attendance and also fully involved. FM will need to address normal operating conditions, dealing with alternative operating modes and coping with emergency and crisis situations.

It is the facility manager’s responsibility to narrow the differences between occupants’ needs and the designer’s goals. Because user groups e.g. clinicians, are rarely able to understand fully the specifications and drawings in spite of any assurances they provide, FM can assist in bridging this gap and helping to learn how to understand plans and specifications through workshops and referral to built examples.

Commissioning involves a ‘get well’ period. This is known as the Defects Liability stage and starts with the building consultants, suppliers, contractors and sub contractors returning to the facility to adjust, fix or rebalance their systems following occupation. This is usually the time when the hospital administrators and staff are

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 539 under great pressure to commence operation from the new facility while the consultants and contractors are trying to finish up their work and where budgets have been almost or fully expended.

Problems to be corrected that were overlooked at the design stage suddenly become potentially disastrous and affect the budget and program; and eventually penetrate a wide range of areas involved in the delivery of health services. Facility managers have a vested interest to achieve a positive outcome even when the building designs are being developed. Having a facility manager available to interpret drawings and designs will mean is invaluable to users and staff. The use of models and in some instances prototypes built at full scale can avoid costly and embarrassing mistakes at the time of hand-over. The commissioning stage is too late to undertake significant changes. If functionality and operational issues are not picked up prior to the commissioning phase then the issues may become compounded/costly/dangerous.

Post occupancy evaluations are important but come about too late and monitoring previous operating and management costs is rarely considered when designing a hospital. Determining the effect of the health facility design on patient health outcomes and assessing design applications based on real findings may be an agenda for the next ten or more years. Research is needed to determine the ways patients’ clinical outcomes might be improved through designed elements of the healthcare environment.

Glitzy buildings tend to be feature-packed, but too often the features don’t sit on top of a functional core. This can be evident when examining why monitoring and metering had been omitted restricting the ability to measure, manage & monitor costs. Introducing capital charging or determining performance becomes impossible. The designer may be completely unaware of the benefits of spending $20,000 on a controls upgrade rather than spending the same amount on a presentation model. How are we to deal with that?

Culture

How are the right people selected to work on hospital projects? Would you select a surgeon to perform your open-heart surgery based on the lowest price? Would you want a gynecologist even if they were the most highly regarded in the field performing your open-heart surgery? Surely you would want the best-qualified professional?

FM is a discipline that provides for the ongoing operation of hospitals and unfortunately has not achieved prominence until recently. In spite of the fact that facility management also has a major influence on the delivery of health services, the discipline is relegated to being one of a host of routine considerations when dealing with annual budgets or accreditation. Too often when cost reductions are required it is the facility management area that suffers the most.

The continued functioning of hospitals’ energy, communications, environmental, safety and emergency systems is critical to the continuity of delivery of the health business. It is the thesis of this paper that discipline of facility management has not

Facility Management and the Design of Victorian Public Hospitals Gelnay, B. 540 been given sufficient opportunity to participate in determining a hospital's capacity to deliver services.

The involvement of FM is critical in the early planning and design phases. This requires a cultural change in the mindset of those involved from functional briefing to commissioning to assess impacts on facilities and associated recurrent costs.

What is needed is a mechanism that cuts across the professional and institutional barriers. Currently design activities reside in a ghetto of politically astute project managers, enlightened architects and building services engineers who have never had to lug tools and spare parts up a restricted access designed for a yoga contortionist. Designers tend to talk up visions, the upsides, integrity and rich urban fabric and not necessarily talk about insufficient resourcing or meeting budget cuts while maintaining higher levels of compliance.

Design consultants directly affect hospitals in the quality of their water and air, the reliability of their electricity supply, the safety and quality of the environment in which health services are provided. Hence the selection of professionals for building projects needs to be based on the right mix of skills and knowledge which includes an understanding of the facility management sector. Are questions put to prospective engineers and architects about their knowledge of facility management issues prior to engagement? In considering necessary competencies, there needs to be an understanding of how building services are delivered and maintained following the design and construction phase.

Engaging an appropriate skilled professional provides greater value to the hospital by allowing for open dialogue to discuss the project thoroughly throughout the conceptual and design stages up to and including the operations. This results in better understanding between conceptual thinkers and those responsible for day-to- day issues of the building’s capabilities.

Cultural Change is needed. The outcome of recognizing the role of FM in addressing these and associated business continuity and contingency planning issues during the design phase will help ensure that increased reliability, lower recurrent operational costs and reduced replacement requirements will lead to better service delivery. New directives that now are to be considered include energy and sustainable conditions. FM has a prime position to provide source info and evaluate the impacts.

Establishing this new approach starts with the need to gain the input of Facility Managers who may be engineers, contractors, building operators, asset managers or administrators in the hospital. It is now important that the FM be regarded as a team member with direct access to the CEO/Board with status of importance equivalent to the DON, CFO and Head of Surgery.

Recognition of the knowledge base and corporate wisdom that resides in FM is long overdue and attention should be given to the contribution that can be made by the and maintenance personnel as seen in commercial sector’s e.g. manufacturing industry, hotel and entertainment complexes.

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Educators are aware of the lack of knowledge in the design sector have now developed courses and programs to address these needs such as RMIT, FMA and Melbourne University. A range of educational opportunities has arisen in asset and facility management and the range of areas extend from short term to extended or degree programs for experienced people or tertiary qualified graduates.

Conclusions

The way to deliver projects is through meaningful interaction between the design and FM areas supported by long-term partnership. The payoff for this is improvement in productivity that can be measured in higher outputs/less staff absenteeism due to sickness/absence/churn. This must be nurtured and maintained as any relationship by being based upon communication, trust and co-operation.

Relationships between parties involved in the non-clinical sector of hospitals should strive to achieve high-class performance by adopting a culture dedicated to continuous improvement throughout the design pro, reducing unnecessary costs, shortening wasted time and increasing quality. It also means getting the design team to revisit the facilities they have helped create to see how well they have achieved the original intent.

The emphasis is to shift from price of design at tender stage to long term value and to extend the horizon kept in view from construction to lifetime.

There is a need to control, approve and review – but by whom and of what?

Balancing long-term benefits and short-term gains, undertaking determination of life cycle period and trade offs between recurrent savings and capital expenditure is carried out. The commitment to outcomes and making the best decision occurs at a variety of times and locations. It is important these decisions not take place as though the people making them operate as though they are in a vacuum. The decision makers need to be guided in part by facility managers.

The thesis put forward is that the FM having been identified as having a significant role and that there should be a number of opportunities for interaction at key stages to ensure the hospital re/development designs meets the ongoing needs of the patients, staff, visitors and other stakeholders.

The key to the involvement of FM in the design process is to have a Facility Manager position with the Hospital recognized, be it an Engineer, CEO, CFO DON, Manager or Administrator. The position should directly report on a regular basis to the Executive of the hospital on Duty of Care and governance issues. By this means it would be possible for the agency when engaging consultants to work on capital projects to have a principal point of contact with a representative who understands and deals with matters such as asset condition and its inherent issues of compliance and functionality, negotiates for annual budgets to ensure service delivery can be maintained and sustained and prepares reports needed to continue operations such as accreditation, annual statutory reporting.

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FOOTNOTES

*1 Refer to DHS sites on Generic brief & Capital Development Guidelines on the following address: http://www.dhs.vic.gov.au/capdev.htm

*2 Refer to the policy set out in the Victorian Governments Asset Management Series.

*3 Refer to the Construction Industry Institute study by researchers from CSIRO, QUT and SAU ‘Benchmarking Energy Use in Victorian public hospitals’.

*4 Refer to Attachment 2 - Table of Functional Areas: The components of a hospital can be viewed as functional areas such as an office, warehouse (stores and archives), engineering, laboratory, retail and hotel facilities as well as specialized areas (operating theatres). Each of these building types has an operating cost, life cycle and contingent liabilities that vary in accordance with intensity of use, hours of operation or performance requirements and the maintenance regime. CEO’s and hospital boards need to recognize these functional areas have differing needs that arise at a variety of times.

*5 Refer to Partnerships Victoria on the Victorian Government’s Department of Treasury & Finance website.

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Attachment 1

Diagram of Stages in the Hospital Design Process Prior to Documentation and Tender.

SERVICE PLAN

BUSINESS PLAN

CONSULTANTS BRIEF

FUNCTIONAL BRIEF

MASTER PLAN

FEASIBILITY STUDY

SCHEMATIC DESIGN

DESIGN DEVELOPMENT

VALUE MANAGEMENT

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Attachment 2

General Wards/Inpatient Medical/Surgical Inpatient Pediatric Inpatient Psychiatric Inpatient Aged Residential

Administration/Support Administration Domestic Services Information Services Linen Services Public Amenities Residential Accommodation Staff & Public Amenities Supply Services

Clinical/Specialist Accident & Emergency Ambulatory Care Cardiology Coronary Care Critical Care Food Services Medical Imaging Obstetrics Operating Suite Radiotherapy Sterile Processing Services

Infrastructure Structure/Shell/Building Fabric Site Engineering/Central Plant Trunk Reticulated Systems Circulation/Travel

Day Treatment Allied Health Day Surgery Unit Endoscopy Unit Pathology/Mortuary Pharmacy

Education & Research

Miscellaneous Child Care Center Community Health Care

Commercial Private Hospital Kiosk/Catering Consulting Suites (Including Private) Car parks (Including Private)

Table: DHS Functional Areas

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Attachment 3

The Missing Link

ARCHITECT FACILITY ENGINEER MANAGER BUILDER

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