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Hospitals

Ask an expert: Hospitals, health care facilities

Health care facility designers are expected to keep pace with increasingly complex, advanced engineered systems and features
By Consulting-Specifying Engineer November 18, 2019

Respondents

Neal Boothe

TLC Engineering Solutions

Boothe has more than 24 years of experience in the health care industry. As Principal/Senior Electrical Engineer, he has led numerous projects, including new greenfield hospitals and additions and renovations to existing health care facilities.

Mark Chrisman

Henderson Engineers

In his role as Vice President and Health care Practice Director, Chrisman coordinates strategy for the company’s health care projects nationwide. His areas of technical expertise include fire protection and code consulting.

Tom Divine

Johnston, LLC

As Senior Electrical Engineer, Divine has spent 21 years in the consulting engineering field, with the past 17 years designing and engineering health care facilities. He is responsible for power, lighting and fire alarm design for hospital and health care projects.

Roger Koppenheffer

Certus Consulting Engineers

As a founding Principal of Certus Consulting Engineers, Koppenheffer brings 24 years of experience in the MEP consulting engineering industry specializing in health care facilities. He has a range of expertise in mechanical and plumbing engineering.

Nick Martin

Affiliated Engineers Inc.

As principal, Martin oversees multidiscipline engineering teams with a focus on national and international health care markets. He originally joined the firm as an electrical project engineer.

Michael Phillips

Southland Industries/Envise

Phillips works with consulting engineers, customers and internal business development staff. He is responsible for educating them on the solutions offered through controls and building automation.

Jose Torres

RMF Engineering

As Health care Team Leader in the company’s North Carolina Building Systems Division, Torres works with organizations such as Duke Health, UNC Hospitals and Rex Health care. He has been with RMF since January 2001.

April Woods

WSP USA

As vice president and mechanical department head of Florida building systems for the company, Woods has played a key role in engineering mechanical solutions for major health care projects. She has facilitated sustainable design for several successful green building projects.


CSE: What’s the biggest trend in hospitals, health care facilities and medical campus projects?

Neal Boothe: Currently in Florida, freestanding emergency departmentshave become very popular. Many hospital groups are expanding their service territory by building FSEDs in areas away from their main facility. In many cases, these FSEDs become a way for the hospital to introduce themselves in a new community. Following this, they may have future plans to expand provide additional services to this community — such as building a new greenfield hospital adjacent to this FSED in the near future.

Mark Chrisman: There are a few major trends that we continue to see: modular design and construction, medical or retail health care and technology. Modular design would include everything from prefabricating head walls to drop-in-place toilets and exam rooms. We are seeing more contractors and vendors offering different aspects of the design and construction that can help in terms speed, cost and ease of installation. With some of the larger recent mergers, we expected to see the standard health care model and it is happening with several traditional retailers offering up a version of retail health care with some simple functions like an exam room, blood draw and even an X-ray room. They are also tying this to general wellness in hopes that you could get a physical or quick checkup and then do some quick shopping afterward. Additionally, many of these retailers have locations closer to the patient/consumer than many of the local health systems, becoming the front door to health care. Technology also continues to challenge engineers, owners and constructors during design and construction like integration of many of the low-voltage systems and way finding in hopes of making the patient experience better.

Tom Divine: Over the last couple of decades, we’ve seen increasing requirements for standby power and for more reliable power. Hospitals want more of their spaces to operate with full function during power outages, calling for full heating, ventilation and air conditioningsupport of those spaces. We also see more imaging equipment on standby power and more of those installations driven by uninterruptible power supplies. In recent years, we’ve had inquiries about UPS support for operating room power. The drivers for these requirements are patient experience, concerns about frequent severe weather events and the increasing complexity and extended restart times of medical equipment.

Roger Koppenheffer: The biggest continuing trend is speed — both speed to market and speed of care. Heath care systems are building more small, stand-alone facilities for specialized care and outpatient services. With enhanced recovery after surgeryshown to reduce the average length of stay, ambulatory surgery centers, especially orthopedics, are building inpatient rehabilitation facilities attached to the ASC. Creative partnerships and collaborative delivery models are continuing to gain momentum as a key to speed to market without sacrificing overall value.

Nick Martin: One of the biggest trends for health care facilities continues to be evaluating whether to decentralize ambulatory care from primary medical campuses. The recent trend suggests the tendency to keep higher acuity level care on pre-existing medical campuses and push ambulatory level care out to strategic locations within the surrounding communities.

Michael Phillips: The biggest trend I have seen is the continued focus on the patient experience. This means the ability for the patient to interact with their environment in different and meaningful ways. Especially as health care facilities compete for elective procedures, they are more aware of the effect the environment has on the patient. This includes lighting, audiovisual options and temperature control.

Jose Torres: In new facilities, the most popular trend is prefabrication. What systems can the construction team start to assemble early? How we take advantage of an abundance of labor in another state? The ultimate is goal is to shorten the construction period so the facilities can be populated early. In the Duke Health Bed Tower Addition (500,000 square feet), the prefabrication efforts focused on the mechanical, electrical and plumbingsystems in the corridor and the MEP infrastructure running vertically through the 11-story bed tower. The Hillsborough addition (90,000 square feet) is focused on the prefabrication of the patient toilet rooms, plus the previous systems mentioned above.

April Woods: Future-ready health care is the biggest trend that we are currently seeing in the marketplace. Owners are getting the appetite for smart buildings, which will require flexible, adaptable building design that is future-proofed for emerging technologies. We’ve already seen the need for robust and resilient infrastructure in our designs to accommodate the most technologically advanced procedures, and health care facilities will continue to evolve into technology hubs that will change how we implement design and support this sort of infrastructure needs.

CSE: What future trends should engineers expect for such projects?

Torres: In the past two years, we have seen requests from the owner and the construction manager to provide early foundation and underground packages at the end of design development and pre-purchase packages for long lead MEP items at 50% construction documents. These requests can be challenging as it starts to limit the flexibility of adjusting the floor plan or change the function of the floor plan. It requires early focus on locking down the floor plan, coordinating critical spaces and the sizing of the air handling units, chillers, boilers, switchgear and generators. Then, it is important to balance shop drawing reviews as the design team is completing the construction documents.

Martin: Speed to market for ambulatory care projects should continue to be a primary focus of health care providers as they compete for market share within their regions.

Chrisman: I expect we will continue to see more health care spaces becoming modularized to help facilitate a faster construction timeline for the owners. Engineers and constructors should be prepared to be flexible with design and installation to accommodate these new features. Also, as health care continues pull in design features from retail and hospitality for consumerism and we focus on the whole being, a focus will be placed on true healing spaces, which will include design features that may not have been as prevalent in years past.

Phillips: The focus on the heath care experience, care efficiency and better patient experience means that engineers should expect to see more approaches to unified room controls or the convergence of technologies that make this all happen. This is the ability to let patients control their environment directly in an intuitive and easy way. In addition to the patient experience, engineers need to reconcile the need for operational efficiency, whether that is in energy efficiency of the facility or technologies that aid the staff in being more efficient at their jobs.

Boothe: Engineers must be thinking about the future needs of a larger campus to include a possible hospital, medical office building, parking garage, etc. In some cases, the owner may want to include future infrastructure with the initial FSED project while in other cases they may want to save this expense for the future construction. Recently, our company designed two new hospitals in the Orlando area being attached to already operational FSED projects. In one instance, at Orlando Health’s Horizon West facility, the owner opted to design and construct a central energy plantwith the initial FSED construction. In this case, we designed the CEP understanding the needs for the future hospital. In a second hospital expansion off a recently opened FSED for Halifax Health’s new project in Deltona, Fla., the original FSED used smaller, stand-alone MEP services initially. This included smaller, exterior equipment such as an emergency generator and air-cooled chillers sized only for the FSED. This owner decided to construct the CEP later as part of the larger hospital project. The hospital design allows future connections for major MEP services so that over time the hospital’s MEP services can be extended to serve the FSED.

Woods: Engineers need to be ready for smart building concepts continue to evolve. They already are becoming the norm and technology advances will continue to increase their implementation. Hospitals built today are expected to operate for many years to come and our job is to ensure that we are designing for maximum adaptability.

Koppenheffer: Engineers can expect compressed design and construction schedules and should play a key role in achieving the best value in a shorter period of time. Developing standards through an owner’s project requirementsprocess to be implemented across multiple projects can shorten the front-end design duration on each individual project. A collaborative design delivery such as integrated project delivery(whether a true IPD contract or not) or design-assist is paramount to maximizing value through designing the way it actually will be built, early procurement, maximizing and designing around prefab opportunities, etc.

CSE: What types of challenges do you encounter for these types of projects that you might not face on other types of structures?

Martin: Ambulatory care requires a comprehensive understanding on how to approach health care facilities with mixed occupancies and different system requirements with regard to codes, resiliency and flexibility.

Phillips: Often you are dealing with technologies that are not found in commercial office buildings, at least not to the same degree. These technologies include way finding, headboard systems, nurse call systems, radio frequency ID resource locations, AV controls and the various ways these technologies integrate. The biggest challenge is that there are a limited number of engineers who truly understand how all these technologies integrate and a limited number of contractors that can do this type of work effectively while maintaining the promised cost savings.

Woods: Stringent health care codes and standards have always been a unique challenge to the health care industry and they will continue to evolve as continued research and development is accomplished to validate these code requirements. New design strategies are being implemented every day as the health care delivery model continues to change and new infection control procedures need to be considered. A delicate balance between patient safety and energy efficiency is continually being evaluated to make health care facilities not only a safe haven for the patients but also a robust, high-performing building.

Boothe: The expansion and connection of existing utilities and systems becomes a major consideration when a smaller building such as an FSED is later expanded with a large new hospital. A good example of this would be the fire alarm design. While a project such as a single-story FSED would have a basic fire alarm design, a large hospital project (which often will include high-rise considerations) requires a more significant fire alarm system. The design engineer must understand that in the initial FSED fire alarm design, system capacity and design considerations must be maintained to allow this system to integrate easily into a larger, more complex system. In the full hospital design, the fire alarm system will require a survivable design (both in device loops and in network loops) that might not be required in a small, single-story initial FSED construction. Further, the hospital fire alarm design will often include voice evacuation-type devices and programming that needs to be considered when designing the FSED, which typically would use a chime system for audible notification only.

Koppenheffer: Historically, women’s services were the primary services deemed marketable. Today, many other services are shopped by the consumer. As a result, finishes, technology and a hospitality feel are becoming more important for units such as oncology and palliative care. The percentage of the overall construction budget allotted to MEP tends to be less, while the more stringent codes and standard of care result in higher overall MEP costs. Operational costs are about more than just energy. Health care engineers must be in tune with the hospital business, paying attention to the impact of design solutions on the clinical operations, reimbursements, Hospital Consumer Assessment of Healthcare Providers and Systemsscores and speed to revenue generation.

Chrisman: A challenge we often face on larger health care projects is staff turnover from the owner side. We have had several projects that took a year or longer to design and then several more years to construct and we ran through several department directors, all of whom had different opinions about space use and function, which required redesign and sometimes changes in construction. These changes can slow the construction process and often have unintended consequences later in other areas if not fully vetted.

CSE: What are engineers doing to ensure such projects (both new and existing structures) meet challenges associated with emerging technologies?

Woods: Even down to the firm level, engineering consultants are starting to understand that many of the innovations and emerging technologies start in-house and do not just rely on outside vendors. These systems will continue to help automate procedures to help improve the patient experience.

Phillips: In my opinion, not enough and not soon enough. System integrators, often under MasterFormat Division 25, need to be brought in early in the design process and not left to be subcontracted out under other trades later after the design is mostly complete. The traditional route of having multiple subcontractors that are all specialists in their fields all brought in under different contracts and different design and construction divisions of responsibility does not produce the best results. Design engineers need to partner early with subject matter experts that are product-agnostic and can understand the technical challenges and how to plan around them.

Boothe: While engineers cannot anticipate the needs of future and emerging technologies, designing systems will capacity and flexibility to allow for these technologies is important. In a hospital environment, the only constant is change — especially as it relates to technology advancements. Engineers must design power systems, air handling systems, chiller plants, heating plants, etc. understanding that the hospital will implement new technology soon after construction ends on a project and that our systems must be flexible and robust enough to support these.

Koppenheffer: There will always be a challenge to balance what is “tried and true” with pushing the limits on new and better, coupled with meeting code minimum versus best practice. As engineers, our job is to fully evaluate all options and to help inform our owners to make a fully informed decision, balancing first cost with total cost of ownership.

Chrisman: Often when working on large expansions or greenfield sites, it is easier to plan for additional space and infrastructure for either new medical equipment or technologies that may be installed in the future. Renovations pose a more difficult challenge for space, but if the right partners and vendors are onboard with the concept early in a project, the design team can educate the owner on possibilities and plans to accommodate these systems in the future with minimal upgrades.

Martin: “Future-proofing” is a term that is often used in our industry to help define how systems installed today can continue to meet the requirements for health care down the road. In some respects, this approach makes sense, but trying to “crystal ball” the future can come at the cost of owners pre-investing in systems unnecessarily. System flexibility and the ability to adapt to future changes without interruption to existing service lines may prove to be a wiser decision rather than over designing for an unknown future.

CSE: Tell us about a recent project you’ve worked on that’s innovative, large-scale or otherwise noteworthy.

Koppenheffer: We recently completed phase one design for a chiller replacement at a 3-million-square-foot hospital in north Texas. The facility included approximately 7,200 tons of chiller capacity provided by ageing infrastructure with five chillers of various size and refrigerant type. The owner’s desire was to maximize the plant capacity within the existing chiller room in multiple phases to address future expansion needs and redundancy while maintaining existing operations of the facility. Our team partnered with the owner, mechanical and electrical contractors and structural engineer to determine the best approach given multiple constraints such as limited budget, space and structural capacity. The challenge was also to convert the dedicated primary to a headered primary pumping system, all while maintaining facility operation during construction. Through our collaboration, we were able to increase the ultimate plant capacity from 7,200 tons to 11,000 tons while using equally sized chillers within the confines of the existing central plant and structural systems. This additional capacity provided the hospital with the ability to serve an additional 900,000 square feet of new construction with equally sized chillers with the same refrigerant and converted the piping system to a headered type with N+1 redundancy.

Chrisman: We recently completed an almost full interior renovation of an existing office building for a new behavioral health hospital. There were many challenges in the existing building including a four-story atrium with live trees that was open to all but the lowest floor. The approximately $61 million renovation project created 47 inpatient beds for mental and behavioral health adult patients with room for future expansion. The building had been vacant for several years before the renovation project and had some challenges found during site investigation and demolition that required coordination with the local authority. Other challenges included residential very close to the project, which became a challenge not only for construction but for locating a new code required emergency generator. Our team looked at various orientations, wind patterns, sound attenuation and acoustics to find an ideal location.

Boothe: An interesting project recently completed by our company was Orlando Health UF Health Central Cancer Care Center — Health Central Hospital. This project included cutting-edge technology of equipment that combined a linear accelerator with MRI. During the installation of this equipment, our company discovered that proper separation was not being provided by the vendor’s installer to segregate different voltage insulation types (based on insulation rating) and class wiring (such as Class 1 and Class 2 wiring) as required by NFPA 70: National Electrical Code. This work was complicated since this wiring had to first pass through a radio frequency filter and run through an MRI room. TLC worked with the contractor, equipment vendor and local review agency to custom design an aluminum wiring trough (as a nonferrous metal) and customize its size, routing and internal configuration to provide all the required separation needed per code.

Woods: Completed in 2017, Emory University’s J-Wing expansion is a premiere health care facility, designed to interconnect acute care services through an extensive concourse system. These bridges allow for connection back to the main hospital and clinics, giving maximum flexibility both to the patients it serves and the clinicians. Designed as a U.S. Green Building CouncilLEED Silver hospital, many innovative concepts were considered to maximize efficiencies, while protecting the patient environment. Due to the high acuity of the spaces, the air handling units were designed to allow for the entire facility the ability to be high-efficiency particulate airfiltered. Special design considerations were given to the combination airborne infectious isolation/protective environmentrooms pressure relationships based on feedback from the infection control risk assessmentthat was unique and continues to keep Emory University Health care as a cutting-edge facility.

During work on a 40,000-square-foot infill at the Nemours Children’s Hospital (Orlando, Florida), a full-size “cardboard city” mock-up of the space was constructed in a nearby warehouse space. The cardboard walls were built according to current floorplans and staff reviewed the layout by rolling a stretcher through it, moving equipment around and making suggestions for changes as needed. Photos: TLC Engineering Solutions

CSE: How are engineers designing these kinds of projects to keep costs down while offering appealing features, complying with relevant codes and meeting client needs?

Torres: Because of the current construction environment, our engineering teams focus on delivering more information earlier in the design process. In our schematic design submissions, we provide air handler, chilled water and heating water schedules, mechanical room layouts, zoning of variable air volumeboxes, control schematics and if time allows it specifications. We are providing more information earlier in the design so the budgets can reflect the design intent and give the owners the opportunity to have real MEP budgets. We are also spending more time with the construction managers to provide value engineering options for the owner to consider to keep the project within budget.

Chrisman: Behavioral health projects are a challenge on this front, often the security needs and associated risks for the patients outweigh the needs of aesthetics and cost. On the aforementioned project, there were some very detailed discussions about safety and risks in key areas to confirm that the systems being designed and installed were appropriate for the ligature- and tamper-resistance needs of the patients and staff. While our architectural partner did a great job of making the space look and feel like a healing environment, we tried our best to match this with the systems in the building but most of these types of fixtures, sprinklers, diffusers, etc. bring an institutional feel because of the need for patient safety.

Martin: Engineers are working hand in hand with construction teams before the conceptual phases to ensure that project budgets assembled at the onset are accurately accounting for engineered systems and (if required) infrastructure upgrades. This relationship continues throughout the project delivery cycle to ensure designs remain in line with projected costs but having accuracy in pricing confidence from the beginning is key.

Woods: The implementation of lean processes and ability to engage subcontractors early in the design process continues to be the best strategy with managing cost and owner’s expectations. As our industry continues to move past a traditional mindset, our projects will benefit from more open-minded thinking and will allow for more on-time and on-budget deliveries. Engineers need to be willing to embrace how collective team thinking can positively impact a project and sometimes that means we need to step outside of our own egos.

Koppenheffer: By partnering with industry experts, the team can help the best overall value to be realized. A collaborative approach allows for continuous pricing to maintain owner budgets and allows the most to be done within the given budget. It also allows the future state associated with master planning to be vetted. For example, by right-sizing the chillers for a project, the lowest long-term operating cost can be achieved at the lowest equipment first cost.

CSE: How has your team incorporated integrated project delivery, virtual reality or virtual design and construction into a project?

Martin: IPD continues to be an optional method for project engagements around the country in the health care markets. It hasn’t quite dominated the market like everyone thought it would eight years ago, but we remain engaged on IDP projects regularly. Many owners have opted to go with more of a design-assist approach, which has an IPD feel but without the contractual agreements or profit-sharing elements. We’ve had numerous successful projects executed under any variety of delivery methods and it really comes down to having the right individuals on a project team who can lead, take ownership and communicate efficiently and effectively.

Boothe: We recently completed a 40,000-square-foot infill to the sixth floor (previously a shell floor) for the Nemours Children’s Hospital in Orlando, Fla. The project included a new cardiac operating room, hybrid catheterization lab, 30 new patient beds and support spaces. The owner rented a large empty warehouse type space during design. In this space, a full-size mock-up was created out of cardboard walls to show the users how the space would function. The owner, doctors, nurses and designers met for two weeklong meetings for each half of the floor and this “cardboard city” was laid out per the proposed floor plans. As the staff reviewed the floor plans in 3D (rolling a stretcher through the spaces, locating real equipment to see space allocations, walking between rooms, etc.) the floor plans were revised. At the end of every day’s work session, the architect would have red-lined plan revisions based on the day’s discussions. When we’d arrive the next day, a contractor would have moved the cardboard walls based on these redline changes to let the staff see the new floor plans with all changes incorporated. This continued for the week until the staff felt comfortable that the space worked for their needs.

Koppenheffer: Our team has advanced expertise in delivering projects with full team collaboration and find that effective implementation of these concepts provides the best value to the client. The key to successful integrated projects and the overall delivery of the VDC model is to ensure that what is modeled is consistent with what is purchased and installed. Our teams must collaborate and work together in both equipment procurement and design. This requires constant communication. If the team loses sight of the end goal and simply works toward “building the model,” it may inadvertently allow the VDC model drive the procurement, causing inconsistencies and possibly oversizing of equipment when procured too early in the design. The teams operate best where every team member supports one another and the project.

Chrisman: While our firm does not currently offer VR services, we have worked on a handful of projects in which VR services were performed by our architectural partner. As this is an emerging technology, most of the owners we have worked with have not standardized a set of project VR requirements. They did, however, attempt to set a handful of achievable goals to help validate the design with staff/users. Some of these projects still involved mock-ups as well to gather data in both settings for future use in the creation of goals when using VR on future projects.

CSE: How are hospitals, health care facilities and medical campus buildings being designed to be more energy efficient?

Koppenheffer: Hospitals are inherently inefficient due to their very nature of simultaneous heating and cooling necessary to maintain proper air changes and pressure relationships. Multiple strategies that are being used to combat this are energy recovery systems, low-temperature heating water systems and various control strategies. The use of energy recovery systems such as heat recovery and heat pump chillers allow heat rejected from the chiller during its cooling cycle to be rejected to the heating water system, thus saving water and cooling tower energy as well as boiler natural gas consumption necessary for typical heating water production. With increases in coil technology a low temperature heating water system is a viable strategy. Supply temperatures as low as 125°F can be used effectively for reheat and can lead to higher boiler efficiencies where condensing boilers are used. Lower heating water temperatures are also conducive to heat recovery or heat pump chillers leading to higher chiller efficiency than the alternative. Modest first cost leads to significant energy savings for the life of the system, making it an attractive strategy.

Woods: Innovations are continual and as engineers we should never stop learning. Our systems, while often sized for peak loads, need to be considered for how year-round operation is impacted. Using tools such as energy models to review total building performance have become the norm and are imperative when considering part load performance. Total system impact needs to be considered in smaller, retrofit jobs to ensure that proper design decisions are being made to optimize efficiencies and operation.

Chrisman: There are some popular trends right now that are “easier” to implement in existing buildings including OR setbacks, LED lighting upgrades or automatic sensors that can be accomplished within existing health care facilities. We have seen many facilities implementing at least one of these items. On new projects, because of the code requirements for airflow changes rates and patient comfort (and therefore HCAHPS scores and reimbursement) reheat is a major energy concern. Using a standard VAV system, the energy required for reheat is inefficient. To reduce the reheat energy required, there should be discussions with the owner regarding options including a heat recovery chiller (free reheat essentially) or using chilled beams, where applicable.

Martin: Many projects are being designed to meet more stringent energy usage demands and occasionally a health care organization will have a requirement to exceed code minimums in favor of more ambitious energy saving goals. However, not everyone has the appetite to increase a project budget just for enhanced energy savings. In most cases additional energy saving measures must be complimented by a compelling return on investment in a very short period.

CSE: What is the biggest challenge you come across when designing such projects?

Woods: The first challenge for highly innovative systems is always cost as upfront capital is always a sensitive discussion with how certain system types fit within the allocated budget. Lifecycle costs analyses should be performed on each high-performing building project to validate the best decision making for the owner. The second roadblock is typically sophistication of the facility personnel that will be tasked with maintaining the system. If the staff cannot be properly trained on how to implement advanced control sequences or technology, then the system will not perform as designed.

Martin: The biggest challenge comes in helping a client to understand and weigh options for high-performing energy-efficient concepts that deviate from what they have traditionally done in the past. Energy savings these days comes with a shift in system configurations and operations. Health care facility groups need to be part of the design process to ensure that when such systems are installed, they can be successfully operated as intended to achieve their intended potential.

Chrisman: The biggest challenge for all energy upgrade projects in new or existing facilities are presenting the upfront cost and return to the C-suite and making the case for an acceptable payback period. Additionally, we have seen challenges with presenting design options that are outside of the norm. No owner really wants to be the first to try a new system or product, which is understandable. It is our job on the design team to understand these systems/products and work with the appropriate manufacturer/vendor to learn where the potential risks may be and how the system/product may benefit the owner long term.

Koppenheffer: While many challenges exist when designing health care facilities, two of the largest are limited space and integration of system enhancements given cost constraints. By their very nature, hospitals include many different engineered systems. The square footage available for clinical need rightfully outweighs that for MEP systems. Integration of MEP system enhancements are critical to energy efficiency, but come at a cost. These two items require a push/pull approach where the costs and benefits both short term and long term can be evaluated to make the best decision for the owner.

CSE: What is the typical project delivery method your firm uses when designing these a facility?

Boothe: We are seeing a large number of design-assist projects. Often, we will see the owner select a construction manager early in the design process. The construction manager and design team will work together to help establish the scope and verify the budget for the project. Then as design advances, we often see the construction manager reach out and select major subcontractors (mechanical, electrical, plumbing and drywall often) during construction documents. This is done for a couple of reasons. First, the major subcontractors help validate the project budget and assist in the value engineering process during design if needed. Second, with how busy our health care construction market is, it can be difficult to get multiple, competitive bidders from the subcontractor market if the construction manager waits until construction documents are completed and tries to bid the job traditionally. Getting the major subcontractors onboard earlier also helps control pricing on these job for these disciplines.

Chrisman: Design-bid-build is still the most common option we have seen but a close second for us is design-build and engineer-led design-build. I would expect in the next couple of years that design-build will overtake design-bid-build as we are seeing more and more owners looking at this option for speed to market and better financial management. Our engineer-led design-build scope is often used on infrastructure projects, like air handler or boiler replacements, central utility plant upgrades, fire alarm system replacements or elevator modernizations at various health care facilities nationwide. It is unique in that the engineering package includes detailed phasing, any required temporary units and equipment that has already been preselected/purchased so that the risk is minimized as much as possible for the subcontractors before the project is bid. It allows for equipment to be installed at a much faster pace than traditional design-bid-build projects.

Koppenheffer: Our experience lends itself to just about every form of project delivery; IPD, design-bid-build, design-assist and design-build. Regardless of the specific contracting means, the projects that ultimately provide the best value to the client are those that involve a high degree of collaboration between all team members and stakeholders. A current project our team is working on models this exact concept. The owner approached us to upgrade their aging infrastructure with the end goal being, “I want the most bang for my buck” with respect to capacities, planning and budget without knowing exactly what the future holds for the master plan of the campus. We were contracted directly by the owner, but quickly recommended bringing on trusted trade partners where we all worked together for right-sizing equipment, early equipment procurement and ultimately delivering the project in record time. The key is developing project goals as a team, understanding individual goals of each stakeholder and developing a team relationship that will carry forward to serve the hospital, system and their patients for years to come.

Martin: So many of the delivery methods being used these days are commonly referred to as “alternate delivery methods.” The fact of the matter is that traditional design-bid-build delivery has become a rarity. What has been referred to as alternate delivery (i.e., IPD, design-assist, design-build, etc.) is now the standard and we commonly work under all these delivery methods on a regular basis.

Torres: In our region, the typical project delivery method for both public and provide health care clients is design-award-build. Projects such as UNC Rex Holly Springs Hospital, UNC Eastowne and UNC Rex Cancer Center used the design-award-build approach. The construction management team is selected at the schematic design level. The construction management team assists in developing accurate construction budgets as the design progressed in each submission. During the design stage, the construction management team provides feedback on constructability and provides alternatives on materials and equipment as the design progress to a 100% completion. Construction managers evaluate areas of the building where prefabrication can take place.

Woods: Our project deliveries have been all different types, but our most typical recently have been design-assist where there is a heavy role of contractor support during the design process. This allows for better real-time pricing and constructability reviews to be done concurrently while the design develops. Contractor input can help engineers make better design decisions when an iterative process is implemented, allowing for continuous feedback to improve the overall end product for the owner.

CSE: Microhospitals are a growing trend. Has your company worked on such projects?

Chrisman: We were recently involved with a health system that constructed a handful of community hospitals. The health system decided early on two main prototypes consisting of either eight or 12 beds. From a design standpoint, the locations were all in a similar climate and had similar aesthetics so there was some efficiency in terms of design and construction. The tough part is that while these locations would be considered microhospitals, they were still designed to I-2 (health care) occupancy so all of the major utility and energy considerations in a normal larger hospital were present and had to be addressed so the cost of construction remains fairly typical with other hospital facilities.


Consulting-Specifying Engineer