Value for Money for Hospital Construction

1. Move less critical functions to lower-cost space

Less intense spaces like this were serviced with ductless plenum air returns and lower-cost fire-suppression equipment, which helped bring construction costs down.

Many 20- or 30-year-old facilities are short on the latest technology and long on high-cost inpatient bed capacity. “Healthcare systems are building more integrated care spaces, combining, say, outpatient surgery and chronic disease management,” says Patrick Duke, senior vice president with KLMK Group, a Richmond, Va., firm that advises healthcare systems on capital planning. Instead of locating such facilities in an expensive downtown campus, they often wind up in a lower-cost suburban strip mall—in what Duke calls “a nice 30-year building, instead of a 50-year monument.”

WHR is advising Methodist management on which departments, if any, can be moved or consolidated. Not every option will turn out to be feasible. “We may end up with areas that cannot move because of scheduling and cost issues,” says Watkins. “Sometimes the disruption and lost revenue from a move are not worth it.”

Some Greenfield projects and expansions create lower-cost space within the same building. The recently opened Beatrice Community Hospital in Beatrice, Neb. (2009 population: 12,564) is divided between an institutional zone—for inpatient, intensive care, and diagnostic services—and lower-cost space for administrative, lab, physical therapy, dining, pharmacy, and other less intense functions.

Omaha-based Altus Architectural Studios designed the 144,000-sf facility to save money by equipping the institutional zone with ducted air returns to each room and a high fire rating, while the low-intensity zone has plenum air returns (no ducts required) from the drop ceiling and lower-cost fire-suppression features. “Mechanical systems typically make up 45-50% of the cost of such a building,” making them a high opportunity area for savings, says Loren Lamprecht, AIA, NCARB, Altus’s president. Altus was able to bring in the project’s construction cost at $223/sf, compared to a similar project in Nebraska that came in at $268/sf—a 17% difference.

In JNU Hospital, Jaipur also, we have provided only fresh air along with Fans which was not critical for patients or there is no necessity of providing AC like Demo Rooms, Corridors, Consultant Rooms, Wards, OPD areas etc. In this campus, ducted air and air-conditioning provisions were provided as per requirement and necessity of department like ICU, O.T., Labs, X-ray, Cath Labs are provided with air-conditioning while other areas like administration block, faculty offices, main entrance lobby are provided with ductable air.

2. Design spaces to increase patient throughput and staff efficiency

Twenty-nine bay observation unit at Detroit Medical Center, a renovation of a 5,800-sf physiotherapy space. A customized headwall design using a modular, prefabricated solution with pre-installed medical gasses works anywhere in the space.

A renovation that created a short-term observation unit at Detroit Medical Center highlights another cost-saving trend. The 29-bed, 5,800-sf unit provides space for patients referred from the ER at Detroit Receiving Hospital, one of nine hospitals in the Detroit Medical Center. The center’s ER traffic has increased more than 60% in the last decade, from 68,000 patient visits in 2001 to 110,000 in 2011, according to Ruth Kremer, the DMC’s communications director.

The revamped space, previously dedicated to physical therapy, accommodates non-acute patients who need less than 24 hours of monitoring. The unit is staffed by nurse practitioners and skilled nurses; staff physicians make rounds and are on call, but are not assigned full time to the unit.

The new staffing strategy was prompted by changes in reimbursement. “Insurers are reimbursing [only] nominally for patients that just receive observation,” says Kremer. The new space is helping the hospital implement a lower-cost staffing solution for an increasingly costly function.

Another way to save money on space is to build less of it. Recent healthcare designs have pared back square footage on lobbies, dining areas, and other nonclinical functions. At Presbyterian Hospital, a new facility in Flower Mound, Texas, HKS Architects steered away from an expansive lobby and created a courtyard off a relatively modest lobby. “The courtyard is less expensive to maintain than an indoor area.” says Shannon Kraus, AIA, ACHA, LEED AP, an associate principal and senior vice president at HKS.

Scaling back nonessential space not only saves on initial costs, but also on long-term maintenance. According to healthcare consulting firm Kaufman Hall, each square foot of space costs $30-40 a year to heat, cool, insure, clean, and refurbish over a hospital’s lifetime.

Designs that allow healthcare facilities to operate more efficiently after the ribbon cutting can add significantly to value. At the new 286-bed Middle Tennessee Medical Center in Murfreesboro, Gresham, Smith and Partners laid out each floor on a 72-bed chassis, broken into four 18-bed pods that operate independently. “No patient room is more than 75 feet from a nursing station,” says Greg Gore, AIA, NCARB, Gresham’s principal-in-charge. This contrasts with traditional designs that had some patient rooms as far as 200 feet from a nursing station. Cutting down on unnecessary walking gives nurses more time to care for patients.

The Role of Design is very important in costing of any project, it depends on our requirements and in what phases it is required. Accordingly, we have to design the project as a whole but in such a way that we have to construct and operate in phases comfortably without affecting our existing system so that cost implication will be lesser. Our Consultant Team designed JNU project as a whole in such a way that in case of future expansion our existing infrastructure will not get disturbed and this we realize in second phase of construction while working at fourth floor whereas our hospital is operational upto Third Floor.

3. Apply Lean principles and integrated project delivery

Patient room at Mercy Medical Center Merced. Using Lean principles, the IPD-based Building Team of RBB Architects and McCarthy Construction Cos. saved the owner $3,725,000 in structural construction costs and $542,000 in MEP costs on the eight-story acute care tower. The team even helped the hospital pick up a $120,000 rebate from the local irrigation district. 

Lean principles, as espoused by the Lean Construction Institute (www.leanconstruction.org), probably have their greatest following in the healthcare sector. Nearly half (47%) of architects responding to a survey of attendees at last fall’s Health Design Conference agreed that “Lean practices, where teams analyze processes and improve operational efficiencies before designing a new facility,” will be prevalent over the next couple of years. Fifty-four percent of healthcare providers said preference for IPD is growing; 83% of architects agreed.

The case of Mercy Medical Center Merced, a 196-bed replacement hospital in Merced, Calif., underscores the potential of Lean and IPD in controlling construction costs while meeting client demands for high-quality design.

The Building Team took a year and a half just in pre-planning and preconstruction.

Strict protocols were put in place to guide construction delivery. Schedule revisions had to be signed off by all subcontractors and the client. Weekly progress meetings, chaired by McCarthy, used short interval scheduling to monitor and control short-term site activities. At JNU Hospital, Jaipur also work was done at a fast pace of work, to keep control on progress, there are weekly meetings between contractor, consultant and client. To review progress, there is monthly progress meeting at site. By doing all these projects completed well within time.

The firms had to commit to hands-on participation by their principals. The client required continuity of the design-assist team leaders who were working with FPMC.

4. Make spaces more flexible for multiple uses

Stamford (Conn.) Medical Center, designed by WHR Architects. The facility’s emergency department will link triage and testing/treatment rooms to move less critical patients more quickly through the ED. This will enable staff to provide a quick evaluation and appropriate level of care.

Making space as flexible as possible so that it can accommodate a variety of functions or be repurposed in the future at reasonable cost is an increasingly popular highest-value trend. In a survey of attendees at last fall’s Healthcare Design Conference, Mortenson Construction found that nearly half (48%) of healthcare provider respondents “strongly agreed” that healthcare designs must put greater weight on flexibility to address uncertainties in markets, care delivery, and patient volume.

To save money for Middle Tennessee Medical Center, Gresham, Smith and Partners took two departments that traditionally have been kept apart—preadmission testing and the ER—and put them back-to-back.

“The ER tends to be busiest in the evening, while the preadmission area is busiest during the day. We put them back to back so that they would provide surge capacity for each other,” says Gresham’s Gore. Each area has 10 equally sized rooms containing the exact same equipment, thus enabling staff to provide either ER care or preadmission testing in either space.

Stamford (Conn.) Medical Center, designed by WHR, employs a similar ER strategy. “If the staff need to do a test like an EKG, there’s a testing room behind the triage space,” says Charles Cadenhead, FAIA, FACHA, FCCCM, a senior principal with WHR. “The goal is to give a quick assessment and the most appropriate treatment as fast as possible.”

The linkage of triage and testing/treatment rooms speeds up this process. Triage takes about 15 minutes per patient, and about 10% of patients are released right after being examined. Under the old protocol, all patients would be sent from triage to an examination room to wait for a physician’s evaluation. Now, the staff can triage and diagnose in the same room, allowing them to treat more patients in a given time period, thereby increasing patient throughput.

5. Use New Technologies and such Specifications to trim construction costs, shorten schedule

Designer of Project divided building in eight parts to enhance work to be executed in all segments simultaneously. Designer of Project uses designed frame in such a way that utilizes repeative form work at site.

At this site, principal contractor uses such construction equipments which reduce time of concreting. By use of construction equipment particularly Tower Crane, Boom Placer we could cover entire rich of building at a faster speed. By use of above, construction work done at such a fast speed that not only reduces time span of project but also reduces cost of project.

Building Teams are using such specifications for flooring and other finishes that speed up work flow. In place of raw bricks, Concrete blocks are used here which fastens construction work at site. Instead of costly GI & CI Pipes, PVC pipes were used at site which are not only less in cost also but are easy to work and work has get speed up. This save time and money—and improve quality of workmanship—in hospital projects, especially in cases where repetitive design elements come into play.

6. Look into performance contracting for energy-efficiency 

Rising energy costs are of increasing concern to hospital administrators. While energy expenses are not a huge percentage of operating budgets, new energy-efficiency options offer more ways to trim utility bills—savings that will only get better as utility costs go up. And because capital investment funds are hard to come by, performance contracting has become a more viable means to upgrade systems without a capital outlay.

Healthcare Providers Agree: DESIGN COUNTS

Improving facilities and their physical design substantially:

·        Improves patient experience 74%

·        Improves staff effectiveness 60%

·        Improves staff recruiting/retention 59%

·        Improves patient outcomes 57%

·        Attracts new patients 54%

Nearly three-fourths (74%) of healthcare providers surveyed by Mortenson Construction agreed that improving facilities and their physical design “substantially” improves patients’ hospital experience. Source: Mortenson Construction, “Healthcare Industry and Facility Design Trends,” January 2012

7. Help clients develop firm standards for construction project

Combined with patient safety and quality of care, cutting costs and adding value are top-of-mind concerns for Building Teams serving the vital and lucrative healthcare sector.

The good news is that healthcare construction, while off slightly from more halcyon days, and remains quite solid. Three of four respondents (75%) to the Mortenson survey said their institutions’ construction activity would be at least “moderately greater” in the next 12-24 months—with 27% saying it would be “substantially greater.”

However, given current economic straits, hospital systems can no longer afford to build the kinds of elaborate monuments that, in decades past, could be justified on the basis of providing a marketing edge. That’s not to say that the next generation of hospitals should look cheap, drab, or utilitarian. But, along with assuring patient safety and quality of care, cutting costs and adding value have got to be top-of-mind concerns for Building Teams serving this vital—and still lucrative—sector. +

Princeton Healthcare System: Applying the '70/30 rule'

 “The 70/30 rule says that 70% of organizational improvement comes from re-engineering your existing operations. The other 30% comes from the physical design,” says the rule’s progenitor, Fred Campobasso, managing director for healthcare at Navigant, PHCS’s development adviser and program manager.

8. Hospital Construction methods lower costs, raise benefits

Although the ultimate fate of healthcare reorm remains in doubt, at least one thing appears certain: providers will need to reduce costs, maximize efficiency, and defend their ,market shares to remain competitive-all while continuing to deliver accountable, high-quality care. That’s tall order, and it’s affects every aspect of organizational strategy, including facilities.

Fortunately, advances in design and construction methods are enabling many hospitals and health systems to deliver high-quality new facilities faster and at a lower cost. One system in the Pacific Northwest, for example is , leveraging these techniques right now to construct multiple new facilities in one-third less time and for one-third less money than if it used traditional project delivery methods.

Some of these techniques are relatively new, while others have existed for decades. But they are all finding increasing acceptance as healthcare providers look to the design and construction industry to help them more cost-effectively deliver quality care in this era of healthcare reform.

Let’s take a closer look at some of these innovations and how healthcare providers can benefit.

Integrated Project Delivery

Integration is a buzzword these days as healthcare reform has compelled hospitals to forge closer bonds with physicians in an effort to streamline the delivery of high-quality, high-volume,cost-effective care. Likewise, integration can also enhance development efforts.

The integrated project delivery method was initially developed in the mid-1990s and is still evolving, so definitions vary. However, IPD can be defined as a system that integrates people, systems, business structures and practices into a process that facilitates collaboration and information sharing throughout the facilities design and construction process, resulting in greater efficiency and superior results. The three primary participants in the IPD process are usually the client, architect and contractor, although consultants, subcontractors, suppliers and other stakeholders often also participate.

When implemented effectively, IPD replaces the often adversarial relationship between architects and contractors with an environment of shared risk and reward. When challenges arise, the focus is on finding solutions rather than assigning blame. IPD can also be tailored to the most appropriate delivery method for a given client and project, whether that is design-build, construction management at-risk, or another approach.

The most dramatic differences between IPD and traditional project delivery methods can be found during the early stages of a project. IPD requires much higher levels of team communication and collaboration. The first phases of a conventional project delivery process are pre-design, schematic design, design development and construction document preparation. Historically, much of that work has been completed by the architect with little or no input from the contractor. Conversely, the first phases of IPD are conceptualization, criteria design, and detailed design and implementation documents. The contractor is intimately involved from the start in keeping with IPD’s more holistic and inclusive approach.

During those initial phases, the IPD team works collaboratively to outline what is to be built–including specifications, costs and schedules–and how that will be accomplished. The terms for the subsequent phases of the IPD process– project buyout (subcontracting), agency review (securing governmental approvals and permits), construction and closeout (finalizing the project)–are the same as those used for a traditional project delivery process, but the actual process is again much more collaborative. When developing new healthcare facilities, the effective implementation of IPD should result in buildings that cost less, are delivered faster and operate more efficiently than those built using traditional project delivery methods.

IPD also better supports objectives pertaining to sustainability–green building–than conventional methods, according to research studies. A 2009 report from the Design-Build Institute of America found that integrated delivery methods are superior in achieving or exceeding Leadership in Energy and Environmental Design (LEED?) certification goals. Those findings are not surprising. Maximizing sustainability requires integration of construction knowledge early in the design process–a fundamental element of IPD.

 

Building Information Modeling

Building information modeling is a key ingredient in what makes IPD possible. Like IPD, the definition of BIM continues to evolve. However, it can generally be described a process that uses three-dimensional, dynamic building modeling software to enable project team members to more fully collaborate throughout the project delivery process.

The capabilities of BIM far exceed those of traditional computer-aided drafting to encompass massive amounts of information, including geometry, spatial relationships, light analysis, geographic information, quantities and properties of building components, such as manufacturers’ specifications. The ability to examine and manipulate a complete virtual representation of a facility and its operations enables team members to identify and resolve potential problems and opportunities before ever breaking ground, dramatically reducing change orders and redesign work.

The precision of BIM modeling software has also allowed certain complex facility components to be assembled off-site in controlled work environments and delivered to the construction site for seamless integration with other building components.

The benefits of BIM produce well coordinated projects that can be delivered more rapidly and efficiently, resulting in schedule and cost savings to healthcare providers.

Tilt-Up Construction

Although tilt-up is a construction method that has become pervasive since the post-World War II building boom, it is not one that has not been used extensively for healthcare facilities. But that could soon change.

Through the tilt-up method, building elements such as walls, columns and other structural supports are created in the form of reinforced concrete slabs. Those components are then placed near their final position horizontally, then literally tilted up into a vertical position and secured.

The obvious benefits of tilt-up construction are that projects can be completed more quickly and at a lower cost than through traditional ground-up construction methods.

However, early tilt-up buildings were easy to spot; those pioneering efforts tended to result in a drab, boxy appearance best suited to warehouses and industrial buildings. They were also limited to one or two stories in height. But recent advances in technology have made it possible to vastly improve the appearance, variety and height of tilt-up panels, making many such buildings indistinguishable from those constructed using other methods. Thus the tilt-up technique has become an increasingly viable choice for homes, offices, hotels, schools–and healthcare facilities.

Aside from the time and cost advantages, another benefit of tilt-up construction is that once a prototype is created, facilities can be easily replicated at multiple locations while retaining the flexibility to respond to each unique market and its healthcare needs.

The Future of Project Delivery

The health system mentioned earlier in this article took advantage of all three of these proven innovations – IPD, BIM and advanced tilt-up construction methods to deliver multiple new facilities, including medical office buildings and freestanding emergency departments. These multi-story buildings were delivered in eight months rather than the 12 months that would have been required for traditional construction. Core and shell construction costs were $70 per square foot, a dramatic reduction from initial estimates of $135 per square foot.

In addition to simply saving time and money, this geographic expansion will enable the health system to make high-quality care more accessible and convenient for residents of a broader geographic area. Moreover, it will be able to do so with buildings that have a consistent look and feel throughout the region, in other words, branded facilities that are immediately recognizable as part of that system thanks to distinctive but standardized materials and other design elements.

And while system executives chose not to pursue formal LEED certification in this case, the efficiencies derived from the information sharing and close collaboration supported by these innovative project delivery techniques are enabling them to design and build some of the most energy efficient healthcare facilities in the region.

This is just an example of how IPD, BIM and other advanced project delivery methods are benefiting one specific provider. But more and more hospitals and health systems seem likely to embrace these innovations as the pressures mount to more quickly and cost-effectively bring quality healthcare to their existing service areas and beyond.

9. Conclusion

So, we can say that project cost of a Hospital Building can be reduce at different stages right from planning part to execution part.

PLANNING

By keeping in view different requirement of hospital related with time, we should plan project in such phases that our initial and overall cost will gets balance. We have to keep planning in such a neither we have to made so much of stakes nor shortage of space. This is also applicable on services also neither we have to planned services which will be required say after 5 years not way off those services which is required utmost. We should provide air-cooling only in that area where this is essential and to be free of those areas which don’t require air-cooling like lobby, rooms of little importance etc. We have to provide neither large corridor nor small corridors. On one side, large corridors are not only wastage of land but also increased cost per sqft of occupational area, on other side, small corridors may be maximum use of area but it will create congestion. So, we have to plan optimum use of area. If our requirement is less, than we have to work in phase wise construction. If we have sufficient funding than we have to built structure first and finishing services work has to be taken in later stage.

Likewise, we have to planned services in phases and trying to avoid to provide such services which is not required at this stage, for which we can make provisions in the systems so that in future our existing system will not gets disturbed.

In Civil Construction, we have to use such specifications that our maintenance cost will be lesser. This can be achieved by using such materials which is easily available and design of product should also be such as that is available easily. We can recommend following specifications to reduce cost such as:-

While Designing Structure Frame Work for Building, our Priority should be Pressed structure, if size of building is large, is size is moderate than we should go for Flat Slab else RCC conventional Beam-Slab.

1. For ICU, OT, Private Rooms, Cath Lab, Rooms of clinical importance- Vinyl Flooring over CC Floor instead of Mosaic Flooring
2. For Wards, Consultant Rooms, OPD,---- Vitrified Tile Flooring with simple Pattern
3. For Corridors/Lobby/Reception----Stone Flooring
4. Tile Dado should be used only in ICU, Sterile Corridor, Toilets, Ward only with certain ht instead of full ht.
5. In other areas, we can use combination of Paints
6. We should go for MS Railing instead of SS Railing
7. We Should use CC Flooring/Mosaic Flooring in Electrical Rooms,AHU,Janitor Rooms, Store Rooms, Shafts instead of Kota Stone Flooring
8. In Fire Staircase, we should go for Kota Stone Flooring instead of Granite Flooring
9. We should provide CRS Door Frame and only when essential wooden door frame can be provided
10. For Partition in Wards, we should go for Aluminium Work which is not only economical but can be re use in case of alteration
11. We should try to limit woodwork because it’s life is limited, wherever possible we should use Aluminium work
12. For Counter which is require in Labs/Kitchen & other areas, we should go for the option that MS frame over which Acid Resistant tiles, this is economical.
13. While selecting False Ceiling we should go for Grid System which is require for maintenance point of view.
14. At the Time of Finalization of Fixtures, they should be economical, durable, and easily available.
15. We should go for Led light instead of normal light which initial cost is higher but operational cost is lesser.

Similarly, for underground plumbing work we should go for CI, GI, RCC/SW pipe material which initial cost higher but operational cost and durability is higher.

EXECUTION

We have reduced the cost at JNU site because of purchasing of materials directly by JNU like: Plumbing Fixtures, Light Fixtures, external Cables, Furnitures, Lifts, DG Sets, Steel etc. thereby saving in cost of more than 20% for these items which cost implication over whole project is huge. Simultaneously executing some items directly by appointing sub contractor on behalf of JNU also reduces cost of project.

Before Start execution work, we have to plan in such a way that we have to use optimum use of machinery which is easily available in market and thus reducing construction span of building, it ultimately reduces cost of building.

If we use conventional methods than we require more manpower and material, if we use RMC than we requires less manpower and work complete at a faster speed.

If we use Builder Hoist, then also work speed is slow but if we use tower crane or Boom Placer work completed at such a fast speed which cannot be completed by use of builder hoist.

 

MEDICAL FURNITURE

We can curtail cost of medical furniture also by developing proper procurement system and advance planning to procure medical equipment and medical furniture.

Above are only few examples, there are several techniques by which it is possible to reduce time of construction more than 50% by use of latest technology and it is possible now that construction cost can be lowered by more than 20% if properly planned in all aspects related with construction of Hospital till operational.