Building safe, effective health care facilities

It’s hard to think of an engineering project with higher standards than a hospital or health care facility—successfully designed and installed systems can literally be a matter of life and death. Here, engineers with experience in the field offer advice on how to deliver such projects with a clean bill of health.

By Consulting-Specifying Engineer November 17, 2014


  • J. Patrick Banse, PE, LEED AP, Senior Mechanical Engineer, Smith Seckman Reid, Houston
  • Daniel L. Doyle, PE, LEED AP O+M, Chairman, Grumman/Butkus Associates, Evanston, Ill.
  • Robert Jones Jr., PE, LEED AP, Associate Director of Electrical, JBA Consulting Engineers, Las Vegas
  • Craig Kos, PE, LEED AP, Vice President, ESD Inc., Chicago
  • Essi Najafi, Senior Vice President/Principal, Global Engineering Solutions, Rockville, Md.
  • Paul J. Orzewicz, PE, Mechanical Engineer, Project Manager, RMF Engineering Inc., Baltimore
  • David A. Smith, PE, EDAC, Principal, National Director of Health Care, KJWW Engineering Consultants, Madison, Wis. 

CSE: Please describe a recent health care facility project you’ve worked on—share details about the project, including building location, size, etc.

J. Patrick Banse: We completed the finish out of about 300,000 sq ft of an existing 1.2 million-sq-ft shell building in Houston. It included clinic space, surgery suite, patient beds, imaging, conference center, offices, and support spaces. Additional infrastructure completion of the mechanical, electrical, plumbing (MEP), and fire protection (FP) systems was needed to make the systems functional and useable for the finished spaces. It was challenging due to the multiple building permits, both new and original, that were needed to be completed and closed out.
Craig Kos: Since the health care market has shifted to providing more and more clinical services in the outpatient setting, many of our most recent health care projects are actually in spaces outside the hospital. One of our most recent projects in the Chicago area is a 15,000-sq-ft clinic in a space that was formerly a retail occupancy developed for a bookstore. The clinic hosted an immediate/urgent care practice; multiple specialty practices including primary care, dermatology, and gynecology; as well as an imaging suite with magnetic resonance imaging (MRI). The biggest challenge in developing the space was that the existing HVAC systems were designed for the open plan of the bookstore, and we needed to adapt and rezone the equipment to work with the new program, which includes multiple exam rooms as well as non-invasive procedure and support spaces. The controls on each unit were retrofitted and a new control system was added to coordinate the equipment operation and maintain/monitor space temperatures. 
Essi Najafi: Global Engineering Solutions (GES) holds several multiyear contracts with large federal users, including the National Institutes of Health (NIH), U.S. Dept. of Veterans Affairs, and the U.S. Army Corps of Engineers for medical facilities worldwide. Recently, there has been an increase in the amount of our work that focuses on the repair and upgrade of outdated MEP and FP systems, primarily in older buildings where the systems have surpassed their useful life. At the Veterans Affairs Medical Center, Washington, D.C. (VAMC-DC), we have updated air handling units across the campus, many of which have been in place since the early 1960s. These replacement projects also take into consideration the hospital’s plans for growth, often requiring that the new systems have the capability/flexibility to meet future needs. Another focus of these contracts has been to retrofit facilities for new users and uses. This is particularly true at NIH where there is a constant rotation of researchers with state-of-the-art equipment and laboratory needs that require updates to the MEP and FP systems. We have also completed more than 50,000 sq ft of renovation and expansion projects at the VAMC-DC to better align its facilities with the needs of its veteran population. This includes the renovation and expansion of the gastrointestinal medical facility, relocating the main pharmacy, and renovating and expanding the operating rooms, emergency department, and new decontamination unit. 
David A. Smith: We recently worked on a new critical access replacement hospital in Prairie du Chien, Wis. This hospital will be located in a new greenfield site on the south side of town and consist of 100,000 sq ft of institutional space and 35,000 sq ft of attached medical office building. The building uses solar domestic water preheat panels, LED lighting, and energy heat recovery chillers. The building is under construction and is slated to open in 2015. 
CSE: How have the characteristics of such projects changed in recent years, and what should engineers expect to see in the next 2 to 3 years?
Smith: Energy use is one of the most critical items in design as hospital budgets/profit margins get tighter each year. Owners are looking to have the most energy-efficient systems that they can afford within their budget structures, but most are willing to look at paybacks as long as 10 years. Many hospitals today use more than 400 KBtu/sq ft/yr, which is the Energy Star 50 level. The American Society for Healthcare Engineering (ASHE) has set an energy goal of 275 kBtu/sq ft/yr for intermediate facilities by the year 2030. 
Banse: I think speed of design and construction will still be a driver on projects. Portions of some project designs are produced in a design assist mode with the engineer of record providing design requirements and permit drawings, and the contractor and trades providing coordinated 3-D modeling. It seems likely this trend will continue as owners see cost savings using this method of project delivery.
Najafi: In recent years we’ve seen a continual increase in the amount of assessment of existing facilities, and the development of program of requirements, also referred to as PORs. In general, these are often the precursor activities to obtaining or allocating funding. We’ve seen an uptick in the number of these assessments and PORs our government clients are asking us to complete. Recently, we undertook and completed an assessment of the VA’s facilities in Veterans Integrated Service Network (VISN) 3 encompassing more than 260 buildings and nearly 8 million sq ft of space. We are in the process of conducting a similar assessment in VISN 5. The information gathered from these assessments helps clients better understand the current condition of their facilities, and the remaining life of various components. This helps prioritize their needs and identify design and construction projects for the next few years.
CSE: What are the newest trends in hospital retrofit projects? 
Robert Jones Jr.: A new trend is creating a pleasant experience for the patient similar to a hotel environment. There is also an increased interest in daylighting within spaces, lighting/device controllability, and intelligent user interface equipment for the patient and hospital staff.
Najafi: Hospital administrators and facilities managers are becoming more and more focused on energy efficiency, even on their retrofit projects, as a way of controlling costs. Research says that the average hospital uses as much energy in a single year as 3,500 households, and about 2.5 times as much energy per sq ft as a commercial office building. Replacing older chillers with newer technologies such as variable frequency drives (VFD), or using air-cooled variable refrigerant flow (VRF) systems in administrative areas can help improve the overall performance and efficiency of HVAC systems. There are also some newer technologies, such as magnetic bearing chillers, chilled beam, and the use of geothermal systems that may be applicable to hospital retrofit projects, depending upon the size. 
Smith: The most significant item is the use of LED lighting to replace existing fluorescent and incandescent fixtures. Premium cost of LED fixtures has decreased significantly in the last several years, and we are seeing paybacks within 2-3 years. 
CSE: What are some challenges you have faced in coordinating structural systems with mechanical, electrical, plumbing, or fire protection systems?
Banse: Short floor-to-floor heights that need to match up to adjacent structure floor levels cause much heartburn, especially when the new areas are design and technology spaces with higher ceiling height requirements. Steel framed buildings will generally have deeper structures than a concrete structure and also can cause space problems. While defining trade zones above ceiling, all systems must be flexible to offset and use any available space to have the systems installed and accessible. Sometimes “too much” height to work with can cause similar accessibility problems as with “too little” space.
Smith: Building spaces above ceilings have been reduced to a bare minimum to reduce general construction costs. Getting ductwork to fit within these spaces requires more fittings, which adds static pressure to the system, increases fan horsepower, and ultimately energy use. Integrated project delivery helps to alleviate these issues as all changes are evaluated based on a cumulative effect on all systems and building construction.
Jones: Smaller existing floor-to-floor structural slab heights combined with architectural requests for higher ceilings in corridors/common areas result in less ceiling space to route MEP/FP services. Large horizontal structural beams within the ceiling space also create challenges to routing large ductwork and subsequent coordination with plumbing, electrical, and fire protection piping/cabling.
CSE: When dealing with space constraints (tight floor-to-floor conditions), what tips or tricks can you offer to other engineers? What type of clash detection systems or software do you use to help avoid problems? 
Paul J. Orzewicz: When dealing with space constraints, you want to lay out the main ductwork and/or pipes first. Not only are they important to the mechanical system, but they also take the most space above the ceiling—they are the stem of the tree. The corridor is typically the best place to start the layout of the main ductwork or pipes. Once the mains have been designed, the next point of focus should be the branch ductwork and pipes that connect to the mains. Always be aware around concrete columns that frequently there can be a 2×2-ft concrete column cap with 6-in. depth below slab. BIM software allows us to take a close look at the heavy “traffic” areas by cutting a section or creating a 3-D view. It has the clash detection function that allows you to run the detection and find out the clash by different categories like, piping-to-piping, ductwork-to-ductwork, ductwork-to-piping, etc.
Banse: Designers should work to minimize the horizontal runs of sloped piping, such as sanitary waste and rain water leaders. Work to define vertical paths as soon as practical. Design long duct runs to parallel routes, rather than in paths that will require the largest duct runs to cross. Centralize mechanical chases and separate vertical ductwork from vertical piping. Other than the 3-D design model, use clash detection software such as Autodesk Navisworks, but be mindful of the clash tolerance. No design will be completely collision-free.
Najafi: One trend that is having an effect on engineering is the focus on patient-centered design, especially as it relates to creating more open and inviting lobbies and public spaces. With ceiling space being limited in these areas, we are having to locate more and more of the MEP and FP systems in the corridors, which typically have lower ceilings. Autodesk Revit’s 3-D intelligence and built-in clash detection capability has been a real asset in avoiding problems between structural, architectural, and MEP. We have found that when Revit is used, problems during construction attributed to structural constraints are greatly reduced.
Jones: Specify low-profile lighting fixtures and wall-mounted fixtures wherever possible. Revit and Navisworks help identify clashes in 3-D if the project is completed in BIM.
Smith: We use Navisworks as our clash detection software. Modeling must take into account pipe and duct insulation as well as support hangers. While in some situations, items may physically fit within a space, it still has to be able to be constructed in the real world. We give our models to the contractors to use in determining their final coordination and fabrication drawings. Successful projects always come back to good planning and communication between engineers and contractors.
CSE: How do you see the design approach for hospitals and health care facilities changing in the next 2 to 5 years? 
Kos: I think health care systems will challenge the design community to create spaces that can accommodate increasingly complex medical procedures outside of the hospital setting. Hospital systems and brokers see an opportunity to fill vacant retail and office space with these clinical functions, so the design community will need to be focused on advising the systems on the proper building infrastructure to support the clinical goals of the space. We will need to really listen to the planned specialties and procedures and try to get the hospital systems to also look at the future clinical functions that may need to be supported in these spaces. The desired clinical functions have direct impact on the space design, infrastructure, and level regulatory oversight.
Jones: Similar to the newest trends already mentioned. Also, an ever-expanding emphasis on energy conservation, sustainable design, and intelligent electrical systems. Increased controllability and operability of lighting, equipment, and communication devices for patients and staff.
Orzewicz: Flexibility is what I hear coming from my owners. With inpatient-type surgeries quickly becoming outpatient-type procedures, hospital spaces are changing functions more frequently and the mechanical and electrical systems need the capacity and equipment put in place to serve the renovated areas without major system overhauls. Also, shared room functions are becoming more prevalent now. An operating room or procedure room needs to be equipped to perform more than just one type of case. 
Banse: More right-sizing of equipment, motors, and duct systems with more emphasis on tighter construction of systems and building envelope to avoid leakage, and more aggressive design to meet mandated energy codes and high-performance building systems.
CSE: Due to the Affordable Care Act and other recent legislation, health care facilities are taking on new roles and ultimately will be designed differently. What new types of buildings, trends, or challenges do you foresee? 
Orzewicz: It has been said that the Affordable Care Act will have an impact on the amount of care to be treated in outpatient facilities. We as engineers are starting to see an increase of new builds and renovation work for outpatient facilities, which means a typical outpatient facility like a medical office building is now performing increasingly extensive procedures that were typically performed in an inpatient or overnight stay facility. This transition in the way health care is provided is leaving the engineer to determine if the mechanical and electrical systems in these facilities now need to meet the standards and code requirements of an inpatient-type application.
Smith: The Affordable Care Act has added a tremendous amount of uncertainty to the health care community due to the fact that the implementation of the law and the cost ramifications on Medicare/Medicaid reimbursements are in flux. Facilities have a very difficult time determining a cost prospectus on building construction with income numbers as an unknown. That is why we have seen a downturn of hospital construction, especially new facilities or major additions. Remodels and creative reuse of space is a present-day necessity. 
Kos: The Affordable Care Act forces accountable treatment of patients by restructuring the reimbursement policy. For example, hospital systems will no longer be reimbursed to treat patients who are re-admitted for the same illness or for treatment of patients with hospital acquired infection. With the focus for reimbursements placed on quality of care, hospital systems have recognized that the cost of treating patients is the greatest inside the walls of the traditional hospital. The growing trend is to move as many functions and clinical services to smaller outpatient health care facilities as systems adopt a hub-and-spoke delivery system in their effort to provide health care services more efficiently. With the hospital at the center of the hub only providing the most acute care, the smaller outpatient centers are tasked with providing specialty services such as imaging, dialysis, immediate care, and outpatient surgery. Constructing a primary care clinic in the past was not much different than constructing an office space. Constructing a clinic now and in the years to come requires diligent review of the building infrastructure and governing codes.
Najafi: How and where health care is being delivered in this country is changing. While the Affordable Care Act and other recent legislation have played a part in this change, so has the high cost of owning and operating hospitals, the needs of an aging population, and the general shortage of physicians. We’re seeing more and more services being moved away from the typical hospital or primary care setting, and into the community. Over the past few years we’ve seen a rise in the number of freestanding walk-in clinics, emergency rooms, surgery centers, imaging centers, etc. We’ve seen this with some of our health care clients, including most recently Adventist Healthcare, where many of these functions are being relocated to retail centers and commercial buildings that were not originally designed to support these functions. 
Banse: In addition to more restrictive policies on infection control that will minimize patient re-admittance, HVAC systems will be under tighter scrutiny to deliver cleaner air in a more directional manner to help minimize the infection potential due to the building systems. When ASHRAE Standard 188P is published (most likely in 2015), Legionella control will be at the forefront of facility manager and design professional efforts. Acknowledging that it is of concern now, there will soon be minimum standards to meet and document in Legionella control.