Healthy hospital success

With hospital projects, it is imperative that engineers get everything exactly right—after all, the lives of patients treated in the health care building may depend on it.

By Consulting-Specifying Engineer November 23, 2015




Richard Heim, PE, LEED AP, Mechanical Project Engineer, RMF Engineering Inc., Baltimore

Tim Koch, PE, LEED AP, Electrical Engineer, HDR Inc., Omaha, Neb.

Nolan Rome, PE, LEED AP, Senior Vice President, ccrd, a WSP | Parsons Brinckerhoff Co., Phoenix

Raymond Schultz, PE, Project Engineer, CannonDesign, Grand Island, N.Y.

Kunal G. Shah, PE, LEED AP, RCDD, President, PBS Engineers, Glendora, Calif.

Tommy Spears, PE, Vice President of Design Solutions, TME, Little Rock, Ark.

CSE: Please describe a recent hospital project you’ve worked on.

Richard Heim: I was recently part of a hospital expansion project in Mt. Vernon, Va., where RMF Engineering provided mechanical, electrical, plumbing (MEP), construction administration, and commissioning services. The existing hospital had two major needs: more private patient rooms and low-temperature orthopedic operating rooms. A portion of the building was extended into a patient tower with three new floors, one of which remained a shell space to be fit-out later, as well as a mechanical penthouse above to serve the space. Additionally, an expansion was added at ground level for two orthopedic operating rooms with a basement mechanical room below to serve the space. Similar to the patient tower, this included a shell space for future fit-out of additional operating rooms.

Tim Koch: The new Parkland Hospital, located in Dallas, is a $1.27 billion health care facility replacing the existing 60-year-old community hospital. The HDR+Corgan Joint Venture team led the design for a master plan of a new 64-acre health care campus, as well as for the 2.1 million-sq-ft replacement hospital. The project consisted of an 862-adult-bed full-service acute care hospital, outpatient center, office center, parking for 6,000 vehicles, central plant, and other support facilities to achieve a new health care campus. Our imperative was to design a health care facility that wouldn’t be limited by space and function in the future. We knew we must be flexible in our designs today to meet the needs of tomorrow—new technologies, new diseases, and even potential terrorist threats to our community.

Nolan Rome: Most recently, I led a group that finished the design of a new emergency department, campus power service, centralized campus generator service, and parking garage at the Banner—University Medical Center Phoenix campus. These are the first phases of an urban-campus master plan that includes a 15-story vertical expansion on top of the new emergency department, separate loading dock, and central energy plant expansion to be designed in early 2016. The project was designed with an integrated co-location arrangement with Banner Health, HKS architects, DPR construction, and daily subcontractor design integration from WD Manor mechanical contractors and Cannon and Wendt, the electrical contractor.

Kunal G. Shah: The Kaiser Permanente Moreno Valley Medical Center emergency department expansion and remodel project includes approximately 10,000 sq ft of addition and remodel to add 16 treatment bays to increase the total bays to 28.

Tommy Spears: Our company is currently designing a new hospital in Conway, Ark., for Baptist Health System. The new, $26 million facility will be approximately 208,000 sq ft and features numerous innovative design elements and construction methods. The 3-story facility will consist of 100 in-patient beds, seven operating rooms, and a Level 3 trauma center emergency room. To maximize efficiency, the facility will feature a variable-primary chilled-water and heating-water system, as well as variable air volume (VAV) with unoccupied/occupied controls in areas with high air-change rates. The building will also be equipped with an energy-management system that will allow problem diagnosis and corrections remotely, as well as a fully coordinated BIM model. Patient comfort features, including flexible exam lighting elements and bedside controls for HVAC and lighting, were also a high priority in the design.

CSE: What business development techniques are you using to gain hospital clients and/or projects?

Shah: In the fierce and competitive health care market, it is very important to showcase our relevant experience ensuring our prospective clients that our team can provide the support needed to deliver a project on time and within budget. Much of our business is through repeat work with our long-standing and loyal clients. Our goals are to serve them with the highest level of engineering service to afford the opportunity to be considered for future projects. To market to new facilities, we work with our contacts and administrators within the facilities to understand the architects working within their facilities and try to open lines of communication to have the opportunity to show our experience. We understand that this business is one based upon relationships, where relationships are key to success. In this light, we just appreciate the opportunity to develop such a relationship on a project or task. Thus, our position is that no project is too small.

Rome: We believe in strong personal relationships and maintaining a reputation through design integrity and team collaboration. Innovation with our project teams and a history of repeat support for our clients, including architects, owners, and contractors, provide the avenues for growth and development that we look for.

Koch: We believe that owners get the most value from an integrated design team focused on their project goals. Our teams focus on quality and on-time deliverables. We understand with projects that "change happens," and the more we communicate (and know what to communicate) the better the outcome. A shared voice and responsibility from all parties provides an efficient design of a successful building. Great design leads to clients for life; designing successful buildings and systems within those buildings leads to repeat clients/customers. When you consider that this entails all aspects and disciplines of a project design team being engaged in the project from schematic design all the way through construction, this simple objective can be challenging. More than 65% of HDR clients are repeat clients, and we have multiple clients that we have worked with for 30 or more years. This is proof that great design of successful buildings is one of our biggest marketing techniques.

Spears: The only technique that TME has found to be continuously successful is pure customer service. Our company has been built on the foundation of customer advocacy, which compels us to constantly adapt our methods and services to meet the needs of our clients at any given time. We seek out innovative ways to help our clients to continue to build their hospitals to meet the demands of today’s health care environment. We put more design emphasis on the 75% cost associated with owning and operating the equipment in the facilities rather than the 25% cost to construct the systems. Any company can design a facility with the highest standards for energy efficiency, only to have those items value-engineered out of the project. Our focus is to help our clients understand the overall lifecycle cost of each aspect of the design and find alternative financing mechanisms that allow them to have a building that functions efficiently and allows them to provide the best possible service to their patients.

CSE: How have the characteristics of hospital projects changed in recent years, and what should engineers expect to see in the near future (1 to 3 yr)?

Raymond Schultz: It seems that all projects are fast-tracked from a design perspective. Engineered systems design begins earlier, and elements impacting building massing and performance should be agreed upon before the building shape is set. Locating main mechanical rooms, louvers, roof-mounted air-handling units (AHUs), cooling towers, chimney stacks, oxygen tanks, transformers, and fuel tanks prior to generating the first renderings can help avoid difficult conversations later on. We are beginning to see Lean processes and techniques embedded in the design process, and contractors are integrated early on. Their insight to equipment location, material applications, staging, and prefabrication help champion MEP requirements and streamline the design/construction process.

Rome: The integrated project delivery (IPD) approaches that we have been involved with in projects across the nation are showing proven improvements for the use of project capital and quality of work. Studies on building envelope and comparative energy analysis for equipment are helping to make informed decisions earlier in the process and to make better use of project capital upfront. I believe the next 1 to 3 yr and beyond will show integrated involvement from the owner’s consultants. Integration of owner-furnished equipment, furniture, low-voltage systems, etc. to the design process will provide for better decision making for capital expense and construction coordination.

Spears: What we are seeing now, and expect to continue for several years in hospital construction, is a fairly even mix of new construction, renovation, and facility infrastructure projects. For many projects, hospitals are moving away from the traditional design-bid-build process to IPD and Lean construction, as these work better for many of our clients to maximize value. Design-build project delivery also has been popular for some clients due to a fast-track nature and quick delivery of the project to owners. The continued increase in facility infrastructure projects is due to the growing maintenance requirements of antiquated systems and a stronger focus on energy cost savings as hospitals struggle with the never-ending challenge of providing quality health care with rising costs and tightened budgets.

Shah: We have seen that schedules and budgets are compressed intensely. With the limited funding and resources that many medical facilities have, they have to make each dollar go further. Thus, we must ensure that our designs are meeting the programmatic goals, but at the same time allowing flexibility to allow for expansion or further development as funds flow. Further, we see a much more integrated team approach to the hospital projects, where the design team and contractor are engaged early and regularly to ensure a project is efficiently designed and built. This early teaming allows the entire construction team to be collaborative and remove the contentious stigma associated with design team-contractor interactions. We have been fortunate to be a part of many great design-build teams where this relationship flourished and resulted in a successful project.

Heim: The biggest difference I’ve seen recently is an effort to not just satisfy the function of the space, but to do so in an energy-optimal manner. Hospitals are occupied 24/7, making it important to reduce energy costs and usage. It was not long ago that it was common to design a constant air volume system, which would satisfy the code requirements, but would not provide significant energy savings. I’m now seeing owners more open to energy-efficient systems, such as VAV and chilled beams, which is providing new design challenges, but the end result is a more efficient building.

Koch: Designers and owners will be continuing to discover the advantages and drawbacks of LED lighting for many years to come. While it was a slow but familiar transition from T12 to T8 and T5, LED technology adoption has been very rapid and is very different from the lamp and ballasts of the past. LED introduces huge benefits in terms of energy and maintenance reduction—but the lack of standards can introduce new and unforeseen maintenance issues to a campus. Now, along with the design of a lighting system, it is also beneficial to educate owners on the development of facility design and maintenance standards and new strategies for replacement stock. Using LED is a decision driven by economics and quality of light and it requires adopting a new way of thinking about lighting. Over the past 5 yr, hospital projects have started to implement more energy-efficient measures in an effort to minimize operating costs as well as environmental impact. In addition, the development of new and different technologies for use in hospitals has led to greater requirements for information technology (IT) spaces and coordination.

CSE: On what aspect of hospitals do you see the most emphasis being placed by building owners? In what areas is your firm doing the most engineering work?

Heim: From a mechanical aspect, building owners are placing a large emphasis on redundancy as well as future capacity within mechanical equipment. We are frequently designing for a space function that will vary and is likely to change throughout the life of the equipment. Owners are looking for systems that are expandable to suit the potential future needs of the hospital. Similarly, we are building in redundancy quite often to give the owner a more robust system. Recently, RMF designed several dual-tunnel AHUs, which produced many engineering challenges, both in design and during construction, but ultimately gave the owner the redundancy that was desired.

Rome: I see owners’ groups currently placing emphasis on making informed decisions earlier in the design process, to understand high-performing, efficient buildings in form and function while also maintaining project financial goals. Our firm is providing early energy services, fire life safety evaluations, and building-envelope studies, in addition to our involvement with MEP design services that we built our core health care business around.

Koch: It is typical for the facility department budget to be continuously trimmed; therefore, managing costs to both construction and operating budgets are key. Sometimes costs simply need to be reduced, although owners see real benefits when the designer embraces true value-engineering discussions. Understanding the owner’s operations is a good start when discussing their processes. Automation is good, and sometimes simpler is better.

Spears: Many health care building owners have recognized that reducing energy costs for their facilities greatly reduces the amount of revenue that they need to bring in. Studies have proven that $1 saved in hospital operations equates to $20 in patient-care revenue. Health care facilities have caught onto this and have started focusing on saving money through decreasing utility costs, as opposed to increasing patient charges. The largest energy consumers in hospitals originate from the HVAC system. As a result, we have been focused on addressing lifecycle cost analysis and energy-system optimization for every hospital we encounter.

Shah: In our recent experience, we have seen an emphasis on infrastructure improvements and reliability. The intent is to have building systems that can support the facility for at least another 20 to 30 yr for hospitals that are being remodeled. Many facilities that went through capital improvement programs in the 1980s and ’90s have infrastructure that needs rehabilitation or replacement. Within the systems, we are seeing a push on replacement of HVAC system and lighting systems to be more energy efficient. Further, we are seeing the implementation of new electrical backbone infrastructure to ensure adequate reliability and capacity is available. Also, we see facilities looking to evaluate their backup power solutions to ensure they have adequate provisions to allow their facilities to function in times of outage.

CSE: What unique tools, software, or systems do you use when working on such projects?

Koch: Implementing computation design during the schematic design process using DIVA for Rhino allows us to quickly evaluate multiple space geometries and façade options to optimize high-quality daylighting options for patients and staff.

Spears: One of the unique tools that TME uses for many health care facilities is the room ventilation schedule (RVS). While the use of an RVS is common, TME’s application of this schedule to identify the demands of various rooms within the facility (exhaust requirements, pressure relationships, etc.) and how those rooms relate to each other in terms of the floor plan, allows us to optimize the systems within the hospital to account for each of those variables. We also use this schedule to create more advanced occupied/unoccupied control systems, particularly for operating rooms, to reduce the air change rates when the rooms are unoccupied.

Shah: Our team uses the industry-standard BIM software of Autodesk Revit MEP 2015. However, we try to take advantage of the various features and support the software allows, such as photometric modeling, daylighting analysis, and overall modeling. In addition, we use psychrometric analysis software to aid in our mechanical designs based on temperature and moisture to provide solutions that are perfectly aligned with the project requirements.

Heim: Our biggest tool is Revit, which allows us to create 3-D models of mechanical systems. Using Revit allows us to spend more time in the design process creating a realistic-looking model of the concepts we want to implement, which leads to a more coordinated set of documents and a smoother construction process. Additionally, we use Carrier HAF, which generates the building loads and energy models. Although there are some limitations, its user-friendly interface helps generate answers to energy options quickly, which is important during the early stages of a project. Lastly, we have been working with a program called Newforma, which helps organize project information as well as process construction administration paperwork, such as requests for information (RFI), shop drawings, meeting minutes, etc.

CSE: Describe your experience working with the contractor, architect, owner, or other team members in creating a BIM model for a hospital.

Rome: I have been fortunate that my last three projects embraced a "draw-it-once" integrated delivery model. We determined what our contracting partners needed to create BIM fabrication-ready drawings, and we provided enough information in our Revit model to deliver the engineering needed for the BIM model. We stay involved through the BIM process to verify the model is delivering the best routings for energy use and owner access. At the end, we can verify our calculations against the model and then remove design contingencies reserved for field routing and more accurately select equipment that matches the fabrication model for better performance. The team must be carefully selected for collaboration abilities. Otherwise, the effectiveness is lost.

Shah: As previously stated, we feel it is imperative for a successful project to have early and constant engagement with the contractor, architect, and design team. Understanding and developing a model is one thing, but understanding construction feasibility as it relates to construction budgets is another. The contractor and the subcontractors are critical to providing feedback on construction feasibility and BIM model development. Many projects now have a BIM execution plan outlined at the kickoff of the project. The level of detail is established to ensure the contractor understands what the design team is preparing and what they will need to develop. Having this clear understanding of scope and effort allows everyone to work efficiently and collaboratively for the success of the project. For larger-scale projects, we have been a part of co-located offices where the contractors and design team are in the same office/trailer. This allows designs to progress and issues to be resolved in real time and in a team manner. Further, the contractor’s BIM model is updated in real time with the weekly updates of the design team model.

Koch: Parkland Hospital was a true IPD process where we embedded our staff with the contractor’s designers. The cost and constructability of the design are continuously reviewed throughout the design process. The result is a more coordinated project, which has a positive impact to the schedule. Understanding the needs and expectations of the owner and contractor is imperative to successful model development.

Spears: As one of the leading BIM service providers in the industry, TME is highly accustomed to working alongside the design and construction team, as well as the owner, to create a fully coordinated BIM model for our projects. These models provide the best systems for the owner by allowing each member of the team to discuss and coordinate various ideas for the project and virtually work through any issues that may arise before the project is actually under construction. The result is a more timely and cost-effective project that ensures the best possible systems and coordination for the owner during and after construction. Coordinating a BIM project with this complexity usually requires regular (weekly) meeting with the entire team, as well as additional weekly meetings between the engineer and various manufacturing companies. This additional effort always results in a better end product for our clients.

CSE: Have you specified a unique water treatment or conservation system in a hospital?

Rome: We most recently were involved in retrofitting a boiler steam plant serving sterile processing and humidification for a surgery department with a blended reverse-osmosis make-up water system and conductivity blow-down system. It has reduced the boiler blowdown by 10,000 gal compared to the previous year and improved the steam quality. Additionally, we have implemented air-unit condensate collection systems on several health care projects that take the condensate back to the cooling towers for make-up. The water savings are tremendous.