The team approach to healthcare projects
Major construction projects and energy retrofits in the healthcare industry can be complex for hospital management and staff. Typically, the need for growth, service line expansion, and infrastructure upgrades readily declares itself.
Selecting design and construction team members and determining the methodology for how they will interact during healthcare construction projects can be a daunting process. The current design and construction trend in the healthcare industry is to accelerate the project schedule to minimize disruption in services on the existing campus. This is often accomplished by the construction delivery method of construction manager at risk (CMAR). This method involves a design phase selection of a construction manager who works with the design team to provide a guaranteed maximum price from partially complete design documents. Typically, the success of this construction delivery process is measured by the ability of the project team members, including design and construction, to work together.
The main entrance lobby at Salem Hospital’s new Patient Care Tower. Source: Terry Poe and Smith Seckman Reid
Salem Hospital Regional Health Services is one of Oregon's largest acute care hospitals and part of the Salem Health System. The 450-bed, 1.3 million-sq-ft facility serves Salem and the surrounding Willamette Valley. In 2004, the hospital was ready to begin the first of a phased construction process to replace its older facilities and upgrade its utility infrastructure. The master planning process resulted in the need for new diagnostic and treatment facilities, a replacement patient bed facility, and a new centralized energy plant (CEP). Because the new healthcare facility was to be constructed in the middle of a healthcare campus with minimal disruptions to existing patient access, the selection of design and construction team members was critical to the project's success.
Salem Hospital chose the CMAR project delivery method and decided to select the design and construction members as a team. The goal of this selection process was to pick a group of design and construction firms that had expertise in the healthcare industry and a history of working together. A successful working relationship would allow Salem Hospital to navigate through a complex construction project and meet its schedule and budget goals. The team was chosen because of their extensive expertise in the healthcare construction industry and their history of working together on similar successful projects. See Figure 1 for the team organization chart of the Salem Hospital design and construction team.
The team approach identified the key project drivers as the design began to evolve. These drivers included sched
and operational efficiency while complying with budget restrictions. The schedule challenge was based on how to build a new patient care tower containing diagnostic and treatment services and patient beds in a way that accelerates occupancy. Achieving early occupancy would reduce overall construction costs and provide access to the new facility revenue streams. Complicating this issue were planned connections to adjacent buildings and the proposed building location in the middle of the existing healthcare campus. The target schedule included substantial completion of the 120-bed patient care tower in January 2009 with prior completion of the CEP, the 35,000-sq-ft-remote laboratory building, and a 10,000-sq-ft dietary fit out project on campus. Figure 2 shows the project time line and phasing plan.
The team solved the project time line issues by releasing early construction packages for the CEP and an off-campus lab. The accelerated construction for the CEP allowed for phased installation of site utility lines serving the new patient tower and other existing buildings on the camp
This also balanced the mechanical and electrical subcontractor labor requirements in a labor-challenged market and subsequently shortened the tower's overall construction schedule. The lab project allowed for critical support services to be located off-campus in lower construction cost facilities, while freeing up existing facility square footage for connection links to the new patient care tower. The dietary project was constructed concurrently with the patient care tower and provided new patient and staff food preparation facilities.
The navigation of operational efficiency issues was accomplished through energy-efficient design and operational coordination with facility staff and local utility companies. The central plant incorporated VFDs on pumps, fans, and chillers; variable primary flow chilled water distribution; and flue gas economizers for heat recovery. Energy conservation measures for the patient care tower included low-E glazing, which lowered envelope cooling loads by approximately 20%; high-efficiency lighting and lighting controls integrated with the BAS; pump/fan VFDs; and airside economizers on the air conditioning systems. The air-handling systems incorporated return fans to maintain required space pressure relationships and allowed for the use of free cooling when outdoor air temperatures negated the need for chilled water usage.
The energy efficiency of these systems was enhanced by the use of premium efficient motors, direct drive fans (to avoid drive losses), and system static pressure optimization. By using energy use intensity (EUI) data from the Commercial Benchmark Energy Consumption Survey , it was shown that the patient tower's designed EUI of 166 kBtu/sq ft is 12% less than an equivalent benchmark building's EUI of 189 kBtu/sq ft. The energy efficiency of the new central plant and patient tower resulted in significant rebates from the Oregon Energy Trust . For more information on the rebates, read the Rebates from Oregon's Energy Trust sidebar.
The project team's operational coordination with the facility staff resulted in an identification labeling system for all above-ceiling fire/smoke dampers and air terminal units. The damper labeling system contained specific information to assist in tracking and operational record keeping. For example, the identification label included system type (supply, return, or exhaust air flow), system served (air handling unit number or exhaust fan number), and floor number. Air terminal units were also identified to assist facility service staff. The air terminal units were indentified by floor number, unit air flow size, constant or variable volume, and a space number that the unit is located above. This labeling system along with the installation of actuated dampers will assist in the damper and terminal unit testing for The Joint Commission accreditation preparation.
Because of company-wide coordination, Salem Hospital agreed to participate in the Portland General Electrical (PGE) dispatchable power program , which uses the facility's emergency generator capacity (4 MW) to reduce the hospital's load on the power grid when the utility company so requests. Under the agreement, PGE covers all generator testing and maintenance costs, including fuel costs, for the duration of the 10-year contract. This program also allowed the facility to use its code required infrastructure to reduce operating costs.
The project team also worked within the budget and schedule boundaries to meet or exceed the hospital's goals for sustainability, future growth planning, and trauma center disaster preparedness. The project achieved 36 points under the Green Guide for Health Care (GGHC) program. The GGHC is divided into two sections, Construction and Operations, which can be loosely compared to LEED for New Construction and LEED for Existing Buildings—O&M . The Salem Hospital patient care tower project achieved all 11 Construction prerequisites and 36 out of 96 possible Construction credits, or 38% of the possible credits. Although GGHC does not have rating thresholds like LEED, and the two systems do not have a direct comparison, if the facility achieved 38% of the possible LEED v2.2 credits, or 26 out of 69, it would have been LEED certified. Additionally, if the facility achieved 36 out of 69 points under LEED v2.2, it would earn a LEED-Silver rating. For more information on the points the project received, visit the GGHC website at www.gghc.org .
Several design, construction, and operational measures taken to achieve this level of sustainability include:
The use of under-slab ground water for an outdoor fountain. The under-slab drainage system removes water located below the basement parking slab year-round through a series of perforated collection pipes, collects it to a basin, and then pumps the water to a decorative fountain.
The water is available for use due to the local water temperatures and relatively mild weather conditions.
Campus growth and future construction phasing plans were incorporated into the design of the patient care tower and central plant.
The CEP maintained the previously noted energy-efficient systems while sized to serve an additional 600,000 sq ft of institutional space.
The disaster preparedness capabilities of the new emergency department were enhanced by an emergency ventilation system. The emergency department's emergency ventilation system is manually commanded through the BAS. This system allows for a 24-bed exam/treatment unit in the regional trauma center's emergency department to be switched from return air mode to 100% exhaust air when commanded during a disaster response situation. View the emergency ventilation diagram in Figure 3.
Exterior water and electric utility connections were incorporated into the design for outdoor staging of triage and decontamination procedures, expanding the facility's emergency response capabilities during a regional disaster event.
The construction delivery process for the healthcare industry has changed over the years from a structured design (bid-to-build format) to more flexible integrated concepts of CMAR (design-to-build), and more recently to integrated project delivery (IPD) where project team members work toward a common goal under a common contract. This additional flexibility provides healthcare clients more options for dealing with their ever-changing marketplace. The critical construction issues of phasing to maintain patient access, infection control risk management to maintain patient safety, and technology revisions during the construction process are all best served by a flexible project team working together to meet the facility's goals. The team selection process for the Salem Hospital patient care tower project occurred in 2004—before the acceptance of the integrated project delivery process. However, the Salem project team operated in this integrated method to support the hospital's objectives, resulting in the central plant's completion by mid-2007 and the patient care tower's completion in May 2009, when it began serving patients. The project's accelerated time lines were accomplished, even with the unforeseen construction of a catheterization lab to meet the community's expanded need for cardiology services. As healthcare construction delivery methods evolve, projects centered on a team approach will have the best chance for success.
Alsentzer has more than 20 years of experience in the health care industry and is a project manger and mechanical engineer with Smith Seckman Reid Inc. in Nashville, Tenn. Denson is an engineer and energy modeling analyst for the Sustainable Solutions Group of SSRCx in Nashville, Tenn.
Rebates from Oregon's Energy Trust
The mission of the Oregon Energy Trust is to change how residents of Oregon produce and use energy by investing in efficient technologies and renewable resources that save dollars and protect the environment. It accomplishes this by collecting a small fee from electricity consumers and redistributing the money through various programs. One such program is the New Buildings Program, which awards up to $400,000 in cash incentives to projects that install energy conservation measures (ECM) in new buildings. These ECMs are measured against either prescriptive-based requirements outlined by the program (Standard Track) or performance-based calculations based on the Oregon Energy Code (Custom Track). An example of standard track incentives includes providing a $20 rebate for each high-performance T8 fluorescent light fixture and $25 for each compact fluorescent fixture. Custom track incentives are awarded to ECMs by giving a rebate of $0.10 for every kWh per year saved and $0.80 for every therm per year saved.
Salem Hospital Regional Health Services completed construction of a new CEP in 2007 to replace an existing plant with a plant that has the capacity to serve several facilities on the Salem Hospital campus, including the new patient care tower. The CEP incorporates several ECMs including high-efficiency lighting, high-efficiency water-cooled centrifugal chillers, VFD-controlled cooling towers, variable-primary chilled water pumps, and premium-efficiency motors. Through the Energy Trust of Oregon's New Buildings Program, the hospital was awarded $106,000 in incentives for ECMs. Figure 4 has a breakdown of the systems that received the incentives.
In addition, the design team is currently seeking Energy Trust incentives for its design of Salem Hospital's new 356,000-sq-ft patient care tower, which opened in May 2009. The ECMs incorporated in the patient care tower project are anticipated to earn more incentives than were awarded to the Central Energy Plant.
For more information on any of the programs offered by the Energy Oregon Trust, visit www.energytrust.org .
Figure 4: ECM Incentive * Note for Figure 4: To earn incentives for a variable-primary chilled water system, weather bin data was used to show that large variable-speed primary chilled water pumps operating proportionally to load used 746,000 kW-hr/yr less than constant-speed primary chilled water pumps, thus resulting in $74,600 in incentives.High-efficiency lighting$1,600Premium-efficiency motors$1,400VFD-controlled cooling towers$19,900VFD-controlled primary chilled water pumps$74,600*High-efficiency chillers$8,500Total$106,000