Healthcare projects are the most challenging building type and complicated to execute in the construction industry. It takes many months of meticulous planning and collective team work amongst promoters for the successful completion of any hospital on time/within budget. It is very critical to engage experienced consultants to pursue an integrated design project. An efficient as well as innovative approach is also vital to make key decisions for meeting the project cost/time for your signature hospital projects.
Need for hospital planning consultants
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CJ Kosalraman
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On an average, in tier II and III cities, the amount of time spent by a doctor in planning/ coordination/ procurement etc. for their hospital construction is nearly 25-50 per cent of their daily productive time. Doctors lose almost ~Rs 30-50 lakhs worth of billable time in the project duration apart from losing patients’ confidence due to their non-availability as a result of ending up entangled in managing various construction vendors. Still the hospital may fall short of their vision due to inadequate planning. Consultants are constantly updated on these latest requirements and follow best industry practices to deliver projects.
With unskilled labour pool becoming unavailable and construction schedule getting aggressive it is more apparent that pre-fabricated building components/ mechanisation is inevitable. Also the finished product is much superior, has less wastage and green credits are very much possible. Hospitals in particular can start operations many months in advance there by generating revenue and return on investment (ROI) earlier than planned. A green hospital is a money saver for the promoters in reducing overall operational expenses for many years to come.
World class healthcare projects, when implemented well, are built with the following critical steps: (a) pre-design/strategic review, (b) operations planning in pre-design, (c) design (d) MEP engineering, (e) project management, (f) building information modelling, (g) medical equipment planning (h) pre-cast construction, (i) vendor & tender management and (j) statutory approvals.
What is pre-design?
Pre-design and strategic review stage of a project involves (a) Ideal site selection choosing a conveniently and easily accessible location to the general public, preferably having two roads abutting the site. We need to ensure that the site area is suitable to construct a hospital of the desired built-up area (FSI, height and setback norms to be ascertained) including scope for expansion in future. It is recommended that the site zone is preferably ‘commercial’ or a zone where the local regulations permit the construction of a hospital at the location without any conversion (b) Concept vetting involves choosing the type of hospital you want to build (i.e) secondary or tertiary care/single or multi speciality/ light house specialities and its dependent facilities, etc. (c) Market study is a necessity to identify the requirement of the immediate and surrounding localities to test out the owners’ concepts. Its results may change the concepts to suit the projected needs of the catchment area. If required, study of households in the target area is also undertaken to cross-verify the real demographic needs for planning the facility in such a way that it matches the needs for success. The study will help forecast earnings/ expected returns, first cut project estimates, and potential competitions in the catchment area (d) Project sign-off at this stage helps to decide on the hospital type and size, the acceptable speciality mix, tentative project budget and expected outcome. This becomes the basis for financial closure to be undertaken by the promoters and will commence the execution of the well planned design for your healthcare facility.
Why should operational planning start early?
Operational planning in the pre-design stage of a project involves (a) an operational planner who considers different parameters to maintain a synergy between departmental locations and operational/functional process flow. Operational planner will coordinate between the project team and the medical team during the project, from concept to commissioning. He/she will involve every departmental custodian at the initial stage for specific details (b) Key points include departmental location, functional cohorting between OPD, IPD areas from diagnostic and supportive services in addition to infection control measurement/ BMW management process, compartmentalisation of departments, and zoning concepts (c) Critical parameters for consideration are bed count and matrix, progressive utilisation of different departments and man power planning. They also include differentiate in-house departments and outsourced relationships. (d) General design considerations include appropriate functional segregation of OPD (15 per cent-20 per cent), in-patient units (40 per cent – 45 per cent), diagnostic services (15 per cent -20 per cent) and supportive services (15 per cent – 20 per cent) so that mixing of patient flow is avoided. Some of the best practices that you may follow in your design of hospital includes separation of critical areas, concept of zoning, ventilation standards, effective use of daylight, isolation wards and other spatial requirements. We need to make sure that clean corridor and dirty corridor should not be adjacent. They should facilitate traffic flow of clean and dirty items separately. Adequate number of hand wash basins should be provided within the patient care areas and nursing stations with a view to facilitate hand washing practice. Separate arrangements for garbage and infectious waste removal from wards and departments in the form of separate staircases and lifts should be made. It is best practice to provide airlock and anteroom before entering into critical care areas.
What is design?
The promoters should make sure to have all the appropriate consultants on the project team before initiation of the design phase. Selection of consultants should be based on references, past experience, and capability to deliver such projects locally. Some of the primary consultants needed are Project Manager, Architect, Interior Designer, Structural Engineer, MEP Engineer, Civil Engineer, and Landscape Architect. In addition some of the secondary consultants for kitchen, laundry, lighting, acoustics, security, information technology, NABH/JCI accreditation and green building may also be required. Before starting any hospital design, the promoter should have a budget, a design brief, a time line and site survey plan/soil test reports. A budget helps the entire project team to stay focused on the cost while the design brief will provide the road map for construction. It is important for the promoters to adhere to a reasonable timeline or schedule so that the project proceeds on track without delay. Any architect or consultant will require a site survey plan/soil test report to commence any feasibility or design process. It provides various features, issues and opportunities on a site and mitigates challenges into advantages for promoter. The design stage of a project involves master planning of site to space programming, leading to concept and detailed design/ tender. In master planning, the process involved is preparation of concept design of the area showing circulation pattern, zoning of various land uses and relevant details, as well as development/redevelopment strategy. It also furnishes a report on measures required to be taken to mitigate the adverse impact, if any, of the existing and/ or proposed development. Space programming will assist in preparing a report on site evaluation, state of existing buildings, if any; and analysis with basic approach to circulation, activity distribution, interconnectivity and external linkages including rough estimate of project cost based on allowable FAR/ redevelopment objectives. Concept stage will provide owners with a site plan, a detailed space programme and departmental blocking/ stacking diagrams. These will help decide where to place diagnostics and treatment vs OPD or in-patient floors which in turn is critical for phasing of the hospital. Detailed drawings/tender include preparation of working drawings, specifications and schedule of quantities sufficient to prepare an estimate of cost and tender documents including code of practice covering aspects like mode of measurement, method of payments, quality control procedures on materials, work and other conditions of contract. It is critical to make sure that the FAR/FSI and buildable area is within the building regulations. The road width abutting the property, set back requirements and ground coverage percentage determines the height of your building. Some of the guidelines followed are National Building Code 2005, Development Control Rule’s, DTCP and local bye laws. A very efficient design will incorporate modular design/construction and standardisation where ever possible. For example, modular grid spacing help in keeping structural cost economical as well as standardising typical room sizes. Engineering design and systems can also be made modular and standardised for maximum efficiency/value for money. Promoters should provide prompt sign offs stage wise to continue the project work and keep time, cost, and quality in check. It also helps to generate necessary audit reports; payment processes and project close outs.
What are MEP Services?
MEP Services design stage of a project includes scope for
(a) Mechanical – Heating, ventilation and air conditioning popularly known as HVAC. It ensures temperature and humidity are controlled in addition to infection/contamination control. Care must be taken to ensure that dust and impurity controls are in place. There are two types of systems available in the industry, centralised and unitary systems. Both depend on the type of end requirement and usage in a building. In the operation theatre it is advisable to install laminar flow with HEPA filters for sufficient fresh air changes. It is acceptable to install fine filtration units with sufficient fresh air changes in special wards such as ICUs. We need to ensure patient wards will require sufficient fresh air and provide cooling for medical equipment based on product requirements.
(b) Electrical – Electrical systems, fire detection and alarms. Its scope includes sourcing and distribution of electrical power, planning the backup capacity and generation source. It is good practice to plan for reducing the energy consumptions using new technologies and renewable energy sources. Ensure proper distribution for meeting the lighting, power and backup power for the building. It is important to design and provide proper earthing system and lighting protection to protect all equipment. Design should make sure that continuous power supply for critical equipment and certain areas are available. It is imperative to plan for a UPS system for critical loads. The design considerations for hospitals should be an easy to operate system, meeting the requirements of sensitive medical equipment and having provisions for alternative/renewable energy systems to reduce energy consumption.
(c) Plumbing – Public Health Engineering (PHE) and Fire Protection System (FPS). PHE deals with engineering aspects of water supply, sanitation and drainage, rain water/storm water drainage, water treatment system and sewage treatment system. Design considerations should include ensuring water requirement to meet the hospital’s various requirements and planning sufficient amount of storage. It includes providing for specialised water requirements like RO water, DM water and drinking water. Infection/contamination control in drainage and disposal systems is of highest priority. BOD/COD demands and TSS levels within permissible limits should always be monitored. It is critical for safe disposal of soil and waste drainage with suitable treatment systems. Ensure that provisions for hot water requirement using solar/ alternative energy systems are in place. Any special disposal system for drainage from radiology departments must be included in the design early on. FPS deals with providing the equipment/facilities for fighting fires. It is mandatory to implement smoke detection and fire alarm systems in hospitals. Design to provide enough storage of water and pumping arrangement to fight fire. Provide visible exit signage to ensure safe egress and ensure travel distance requirements as specified by the NBC are met. Providing specific suppression system for equipment rooms and critical areas are best practices.
It is very important that comprehensive coordination happens between an MEP engineer and other consultants such as the architect, structural engineer and interior designer. Coordination with the architect ensures proper space allocated for equipment rooms, well planned service shafts and compliance for fire protection requirements. Interaction with structural engineer assists in planning the loading for heavy equipment and beam sizing to accommodate services with sufficient ceiling clearance. A good ceiling design results with coordination of false celling layout with interior designer. Some of the guidelines followed are National Building Code, ASHRAE, NFPA and NABH Standards.
Why is project management ‘mission critical’?
It is very important for the promoters to transform their vision into a successful venture. Alongwith numerous hours and efforts spent in planning to build a hospital, a professional team experienced in managing the delivery of such a vision is a top priority. A single source entity responsible in coordinating the entire project team to meet the budget, time line and quality becomes mission critical. Project management is the overall planning, coordination, and control of a project from concept to commissioning. It shall manage all packages not limited to: civil, mechanical/electrical/ plumbing/fire fighting, voice & data, kitchen, medical gas system, signage, interiors – furnishing, fitting & equipment, medical equipment and external works. It has two main components namely, design management (DM) and followed by construction management (CM). While DM coordinates project brief, design of project, material finishes, specification, tender etc, CM takes care of quality, cost and time. One of the critical roles in project management is contract administration which lays out project strategy, project control system, document control protocols and general administration. Design management involves preparing a project brief, design coordination with consultants, design peer review, value engineering and advice promoters on build ability factor which affects the budget. In construction management, the focus is on quality assurance, site logistics, communication/coordination with the entire project team, maintains schedule, manage construction cost, preparation of operations & maintenance manuals and close out. Promoters should appoint a project management consultant prior to beginning a project to help him/her guide through the entire project process and as a client’s representative, safeguard the promoters interest and get the best building product at the end.
Building Information Modeling (BIM) is virtual construction of a facility prior to its actual physical construction using a 3D building design software portfolio of interoperable BIM-based products that supports each phase of your workflow. It intelligently connects building components/assemblies, aids to revise the design instantly and provides accurate bill of quantities including real time accurate 3D views/early clash detection. It helps in decision-making throughout the design phase which is important in any healthcare project design. Converting existing 2D drawings of a building into 3D model becomes very easy. Its capability to do instant design revisions is the biggest advantage for the project team. BIM’s 3D modelling helps promoters to assess the merit of any new design proposal and its effects with all engineering and medical equipment. The virtual walk-throughs help to identify and resolve problems even before walking on site. Most clashes happening between engineering services are identified at design stage itself and resolved even before the construction begins. Any clashes detected later during construction results in delay and costs lot of money for corrective action. In addition, BIM helps to create construction budgets faster and that are near accurate. An owner can efficiently utilise and ultimately achieve major reductions in real estate expenses. Interestingly, BIM enables early commencement of construction and a seamless coordination among the entire project team.
Medical equipment planning involves meticulously identifying and ordering appropriate equipment per promoters budget, type of care of hospital, type of purchase, upgradeability, patient safety and uptime guarantee taking into account ‘mean time between failures’ including speed of online/offline servicing. It helps to set out a clear selection criterion to identify and order according to supply time or at the right time of the project stage. Promoters need to make sure that the appropriate service engineer/technicians are available for certain equipment. A key parameter to consider is the year of equipment introduction into market followed by its consumable availability and quick restocking of the same. Prior to selection of equipment, check out the number of similar current installations and client references. At times, promoters have the option of signing ‘buy back option’ for certain major equipment. It is absolutely important that the end users are well trained in using the equipment. The infrastructure requirements for medical equipment such as site area, structural, MEP, etc need to be well planned in advance during design stage. It is prudent to be aware of the operating life span of major equipment and the needed warranty/ cost of AMC or CMC. A bio-medical engineer need to be recruited prior to equipment arrival at site and site readiness has to be confirmed prior to delivery.
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Precast construction
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How to build hospitals faster today?
Precast construction is a construction product produced by casting concrete in a reusable mould or form. Using precast slabs, beams and columns will save considerable cost and time as time-consuming shuttering and scaffolding are avoided. From the longevity of the building to the structural soundness, it is the most revolutionary technology in the construction industry. Exponential development and expansion of our towns and cities brought in a need for faster timetables and lower costs in the construction industry. Lack of labour and an undulating market doesn’t help the construction industry which looks at long term developments. Precast technology is an apt solution for such needs, technology that can be trusted; that is cost effective and has uniform quality. From the longevity of the building to the structural soundness, it is the most revolutionary technology in the construction industry. Precast technology has been used to build everything from manufacturing industries to commercial and residential projects including low-cost housing and even flyovers and bridges. The cost of precast building will depend on the size of the project, location, type of building, floor to wall ratio, shape of building (number of repetitions) and taxation as applicable (ED, VAT, Service Tax etc.).
How to manage vendors?
Vendor/tender management is most critical for effectively managing any construction project. It involves preparing and implementing strategies and guidelines for the procurement of all project services and materials, taking into consideration any specific conditions of the project in terms of appropriate contractors, design, manpower resources, time, long lead items, local requirements and site conditions. Before issuing a tender, it is advantageous for the promoters to include as much information as possible in it to get the best comprehensive quote. Tender documents should be at least 80 per cent ‘Good For Construction’ drawings with specifications to receive the most competitive and realistic bids. Vendor’s selection must be based on their prior experience of similar building type, past track records and client reference. It is advisable for promoters to visit vendor’s prior works and verify their references. It is always best practice to get three quotes, shortlist two vendors and finalise one for your project. It helps to bring in transparent selection process and inculcates professionalism amongst the entire project team. Promoter should have a team or a PMC to measure and verify bills submitted for payment by vendor. Only consultants will be able to assist promoters in appropriately paying any vendor for works completed. The recommended sequence of managing vendors are as follows: get quotes, finalise price, issue ‘Letter of Intent’, award work order, pay advance to start work, review shop drawings and technical info, make material payment, make work progress payment, issue final payment after consultants certifies bills. It is best practice to demand as-built drawings, warranties and AMCs from vendor prior to final settlement of bills. A completion certificate from the vendor will ensure that all work is in place and assist in warranties initiation. Vendor should provide a team chart or list of key members working on the project.
General recommendation on approvals – infrastructure related only
It is important to make sure that all required statutory approvals are obtained for your hospital project. Fire/building approval are the most important ones followed by Pollution Control Board, Electricity Board and Water supply. Depending on the size and location of project MoEF/EIA may apply. Always follow implementation of approved drawings and construct only the allowed built up area in a hospital. It is prudent to take time to prepare statutory approval drawings and not submit in haste. If not, too many corrections will delay the schedule of thr project. It is smart to appoint local liaison in that jurisdiction locally to effectively coordinate with authorities irrespective of appointment of architect/consultants. I recommend promoters to keep their entire ownership documents ready prior to submitting for statutory approval.
Interestingly, there is no 100 per cent cookie cutter or no ‘one size fit all’ model for hospital design. Each hospital is unique just like its promoters, their vision, mission and their standard operating procedure. Doctors/promoters should take first mover’s advantage in embracing innovative ideas to build world class facilities and stay ahead of the curve!
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