When the Eifel Tower was built, it took two years and several hundred workers. The tower was built for the 1889 World’s Fair. Today, it attracts more paying visitors than any other tourist attraction worldwide.
President Herbert Hoover officially dedicated the Empire State Building in 1931. Construction took just over a year and came in under the budget of $40 million. On any given day, there were 3,400 workers employed in constructing the skyscraper.
The Burj Khalifa Tower in Dubai stands 2,717 feet tall. Construction began in the fall of 2004. The building’s exterior was completed in 2009 and the project was completed in January of 2010. The exterior features 28,261 glass panels and the tower includes 57 elevators. The project required 431,600 cubic yards of concrete and 39,000 tons of rebar. Twenty-two million man-hours of labor brought the project to a successful finish. For now, the tower is the world’s tallest, but that will soon to be eclipsed by the Jeddah Tower in Saudi Arabia.
The approach to construction projects in the health care setting requires many of the same considerations as these historic projects; careful planning, the expertise and manpower to pull off the project and funding, along with safety and materials considerations.
Rome wasn’t built in a day and most construction projects, additions and renovation projects require extensive planning, schedules, materials and equipment. Tighter health care budgets have made any new project an exercise in necessities versus allocated funds.
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In health care facilities, the input of the HTM department is a crucial part of the process.
Speaking about both construction and medical facilities, Eddie Acosta, MBA, CBET(e), CLRT, director of business development for Colin Construction Company says that “there have been many discoveries in both fields including building codes, safety and health codes and including advance technology discoveries.”
Acosta has a unique perspective on construction in the medical facility setting, having had a long career as an HTM professional in both civilian and military settings.
“In retrospect, the insights that I can recommend the most are to develop a comprehensive project plan, bring in the experts and partner with an experienced health care construction company. Each project is going to be unique, so whether it be new construction, renovating an imaging space or an expansion, it all starts with a plan,” he says.
Acosta’s experience in both settings has offered him an opportunity to see how the process unfolds from all angles.
“The process starts with the initial site visit to determine the space requirements for the new technology with the customers’ needs and wants. This is when a team consisting of the users of the technology and engineers can express their expectations to OEMs, designers, architects, contractors and sub-contractors,” Acosta says.
“This allows the development of a construction proposal for the requirements to integrate the new technology. This will then be added to the cost of equipment for budget formulation and approvals for implementation of the customer’s health care strategy,” he adds. “With the information gathered, a project plan can be developed with all the details that include removal of old equipment and demolition of existing space. The plan will also include upgrading the space to current health and safety codes, utilities, building codes and any new local requirements.”
Acosta says that in addition to these steps, finishes for the project are selected for paint color, lighting fixtures and artwork.
“A timeline will be established with the project plan that will include the installation of the new technology once the space has been prepared,” he says. “Having partners in the project plan that include designers, architects and sub-contractors is key to being successful and completing projects on-time and on-budget.”
The HTM Checklist
Leadership in the HTM department can benefit by carefully considering resources, purchasing decisions, training, skill sets and warranties, among other things leading into a construction or renovation project, according to Matt Royal, CHSP, CHEP-FSM, CHTM, CLSO-M, CHC, CHFM, CBET, director of biomedical engineering for Eskenazi Health in Indianapolis, Indiana.
“Get the inventory of all new equipment correct, this is the time where you have all the purchase orders, pricing, PM schedules, warranties, etcetera,” Royal says.
“Additional resources are needed, it takes a toll on the a team when they are required to not only continue to support an old facility but oversee the installation of new equipment and the movement of existing equipment to the new hospital,” he adds.
Royal says that typically new technology is purchased for a new hospital and this can make current skills at the old hospital obsolete. There can be a large learning curve in the first couple of years as techs learn to support new equipment.
“Ensure training is included in the purchase, typically the builder will hire a project manager who procures the equipment and ensuring training and service keys is the last thing on their minds. You have the most leverage to get this included at the time of purchase,” Royal adds.
Royal also says that the HTM team needs to add IT skills to their tool bag. Either hire a biomed/IT hybrid or send multiple members to IT certification training such as A+, Net+ and, especially, IT security.
“Evaluate all products for cybersecurity, perform a risk assessment during new equipment evaluation,” he says.
“Determine who supports what; there are some gray areas when it comes to technology such as cybersecurity, servers, integration, medical systems and software that reside on common computer desktops,” Royal says.
He says that a misconception with a new hospital in the first year is that all the equipment is under warranty and things are easy to support.
“This is a huge myth; managing warranties are difficult and if the first year of maintenance is not included, it can result in unplanned expenses. Traditional warranties start when purchased, ensuring purchasing language that warranties start at first clinical use is important,” Royal says.
Big projects can bring some new leverage to the HTM department.
“When a biomed puts on the medical equipment planning hat, many other issues become a necessity to consider and plan for. One of the biggest opportunities, and also challenges, is that during major renovation and construction, you are presented with an opportunity to consider vendor relationships,” says Rodney Nolen, clinical engineering manager for University of Minnesota Health in Minneapolis.
“What I mean is this; because of the large spend associated with projects, you are in a position to consider or change who your preferred vendor might be. This is a responsibility, a challenge and an opportunity all wrapped into one,” he adds.
One of the projects that Nolen honed his planning skills on was the development of an IMRIS suite.
“The planning of the IMRIS suite is very carefully planned based on the physical shape and size of the room. No two IMRIS suites are exactly the same so every detail must be considered. The ‘doghouse’ is oftentimes a big topic of conservation. This is the location where the magnet will rest while not in use. This space is critical in the calculations and considerations of the Gauss lines which determine safe distances away from the MRI,” he says.
Knowing the Phases
Knowledge is power and a thorough understanding of the process, from early design on, is beneficial to HTM professionals according to Gregory Herr, BSEE, MBA, CCE, CHTM, director of Healthcare Technology Management at The Christ Hospital Health Network in Cincinnati, Ohio.
“First, it is important to understand the architectural process. There are multiple phases. The equipment planning process crosses all of these: Phase 1-schematic design; phase 2-design development; phase 3-construction documents; phase 4-bidding; and phase 5-construction administration,” Herr says.
“Getting involved in the schematic design (SD) offers [an] opportunity for HTM to have important input on the medical systems. Often equipment planning begins in this phase with general specifications, e.g. 1 CT or 2 CTs, and identifying all of the architecturally significant equipment (ASE). The first pass on the inventory and requirements, both ASE and non-ASE, start to be developed here. For HTM to act as the equipment planner or the lead for the equipment planning, this is where HTM needs to get involved,” he adds.
Herr says that during design development (DD) is often where the actual ASE equipment is identified and chosen by an equipment planner.
“For HTM, this is where equipment decisions and infrastructure requirements (HVAC, networks, electrical) and serviceability are made and it is important for HTM to have input. If HTM is to manage the healthcare technology equipment/systems, the DD is where major decisions are made,” he says.
Herr says that equipment planning is a service needed during any project and involves the initial specifications in SD and ends with final delivery, installation and coordination of equipment to be operational for the go-live date.
“Equipment planners may not be specific to medical systems, and include furniture, carts, IT systems, network planning, electrical requirements, etcetera. HTM can offer specific knowledge and requirements of medical systems. If an HTM service does not have the resources to be the medical equipment planner, often they can be the service that contracts and controls the medical equipment planner. In any case, HTM needs to be closely aligned or control the medical equipment planning,” Herr says.
He also says that not being involved can lead to non-standardized equipment, inefficient designs for service/support, and either not enough equipment, too much, the wrong type and major connectivity missed.
“Equipment planning also means to make sure the equipment is ordered, deliveries coordinated, and a plan to have deployment completed by the dates specified, with application training, infrastructure connections and testing, and coordination of vendors. HTM can own a lot of problems after the construction is complete if not involved up front,” Herr adds.
With the inherent pitfalls and opportunities in every construction or renovation project, there are some lessons to be learned.
“Clearly define who is responsible for every item in the project with a responsibility matrix,” Nolen says.
“For example, if you place a scope washer in a project, who is responsible for making sure the plumbing is completed, who has the electrical, and who is completing the overall install? A document should be created to capture all of this and then followed,” he says.“Always communicate all issues and concerns to all members of the team. More issues result from ‘sidebar’ meetings than anything else,” Nolen adds.
In 2014, Gundersen Health opened a new 500,000-square-foot hospital addition to its La Crosse, Wisconsin campus. This allowed Ryan Motl, manager of IS Clinical Engineering at Gundersen a chance to sharpen his project teeth.
“With any medical facility project, the institution and the end-quality of the project will benefit immensely by having a comprehensive strategy and representative to advocate for the needs of the medical equipment. The HTM department is uniquely qualified to do this,” he says.
“A clinical department will often represent their usage and workflow needs, but the needs of the equipment are not always well understood by the user, and there are many details that are not apparent in the spec sheets provided by the OEMs. The HTM professional should also help translate project needs between the architect and the end user, as well provide thematic information that an individual department may not know,” Motl adds.
“For example, the echo department may not communicate with the OB and diagnostic ultrasound departments regarding site planning, as they are all under separate leadership and spaces. The HTM personnel can identify areas that coordination between all three departments will be needed, and help foster those conversations. All of this is true, even if a medical equipment planner is provided by the general contractor or architect,” Motl says.
Modern technology can save some money and wiring.
“In a large project, the infrastructure needs can really add up. In our experience, we were able to save considerable sums from original design by more carefully tailoring network drops, which were too prolific at first,” he says.
“Having a good understanding of network principles (wireless and traditional), frequencies, heat load, and electrical is key for making the design and build process go forward with minimal re-work. Fortunately, as medical equipment evolves, it tends to be smaller, more efficient, less heat load and is wireless – all of which makes the planning and installation easier and less costly,” Motl adds.
Construction Company Perspective
Getting some insights from the HTM angle is good to know and potentially actionable. One perspective that isn’t always heard is the view from a construction project manager. It is a perspective that makes clear how many considerations exist in planning these projects.
“Patient and staff safety is every hospital’s primary goal. Good space planning greatly lends itself to supporting this goal. To design a safe room, consideration needs to be given to ingress and egress, clearances around fixed equipment, space for ancillary equipment, ready access to consumable supplies and, in some cases, access to emergency equipment such as defibrillators and code blue equipment,” says Derek Contizano, project manager for Colin Construction.
Contizano also says that lead-lined walls need to be well constructed and tested to prevent long-term radiation exposure to technicians. Heavy doors are now being coupled with automated opening devices, which allow caregivers to deliver gurney-bound patients without reaching, opening a heavy door, or touching any surfaces.
“In rooms with swinging booms, we will often make the areas the boom can swing through a different color on the floor. A staff member can know based on the color they are standing on if they’re in the swing radius or not, which cues them to be more aware of the heavy, moveable objects around them,” he says.
While lighting is a design element in home construction, it takes on a new importance in the health care setting, with efficiency being a key element.
“LED lighting is the new standard, because they use less energy and generate less heat than typical lighting systems. The reduction in heat generation greatly benefits the facility by reducing the power bill at the lights and the mechanical units, ” Contizano says.
He adds that lighting must be strategically spaced, based on the types of procedures that will take place in the room.
“More sophisticated rooms will have multiple light types and dimmer controls that allow individual or small clusters of lights (zones) to be controlled independently of each other. This allows individual care providers to customize their environment based on their own personal preferences. A right-handed surgeon and a left-handed surgeon may stand on different sides of the patient table, and will want to change the lighting to suit,” Contizano says.
He points out that mechanical codes are changing at a drastic rate and one of the most critical areas in planning is HVAC.
“Requirements for air changes and outside air have grown considerably since 2013. Most construction activities trigger mechanical changes. Unfortunately, these are often the most expensive and maintenance heavy systems in a facility,” he says.
“In order to meet the requirements, many of our projects have had to include supplemental cooling, humidity and exhaust components. Planning for future HVAC needs is exceptionally critical, as utilizing existing capacity for new spaces is oftentimes a far easier proposition then repairing, modifying or adding onto existing HVAC systems,” Contizano adds.
With an understanding of the total construction or renovation process and the experience of those HTM professionals who have gone through the rigors of gaining this knowledge before, the HTM department can remain an important resource from the beginning.
“Things like this are where an HTM department can really shine and prove their value outside of inventory, PM and repair activities,” Motl says.
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