Planning For Equipment In Acute Care Capital Projects
The aim of this research is to investigate if medical equipment is sufficiently considered during the business case and briefing stages of acute hospital capital projects and what, if any affects this has on the success of a project.
It is likely that a good project “Brief” will be the blueprint for the successful development of any end product. In the context of a healthcare building development, the “briefing process” is the clients’ portal for informing others of his/her needs, defining the projects vision, aspirations and goals. The “Brief” is a formal document which provides detailed instructions on the client’s requirements to the building designers. (CIB, 1997)
Buildings are expensive to design and to realise, and they determine or influence patterns of service delivery for many years, so it is critical that the “detailed information or instructions” given to designers provide clear and concise definition of what outcomes are required, how these outcomes were arrived at and what needs to be created in order to achieve them. Sir Michael Latham’s report, “Constructing the team” (1994) observed that poor briefing can cause buildings to be “wasteful of resource or defective in use”.
In 2005 there were over 600 National Health Service (NHS) Trusts providing a range of primary care, acute, mental health and ambulance services throughout the UK (Davies, 2004). The complexity of the NHS and changes in the funding of capital healthcare projects, including the introduction of the Private Finance Initiative in 1997, have created significant challenges for both the healthcare building designers and the guidance writers. (Hignett & Lu, 2007)
Following the publication in 2000 of The NHS Plan (DOH, 2000), which set out a programme of investment and reform in the UK healthcare sector, the largest hospital building programme in the history of the NHS is nearing completion. By 2010, the DOH is on course to achieve its target of 100 new hospitals, of which the vast majority have been delivered through PFI. To date, 131 hospitals have been built or are under construction as part of The NHS Plan at a cost of £12 billon. (AMA Research, 2009)
With the UK currently experiencing a significant economic downturn and The NHS Plan programme due to end in 2010 the outlook for new healthcare projects would seem less certain. However the UK government is now looking to provide stimulus for the construction industry by bringing forward further development of the healthcare estate. The UK government is planning a substantial funding increase for the healthcare sector over the next 3 years. With a reported £21bn planned on healthcare projects during the 2008-11 period, (AMA Research, 2009) the NHS cannot afford for inadequate briefing leading to inefficiency both financially and in terms of the current and future service delivery.
A key element of the brief for healthcare projects is the detailed requirements for medical equipment. With the pace of changing technology, particularly around the sphere of medical imaging and diagnostic technologies, acute facilities are set to evolve into the last resort treatment site, with only the most critically ill patients being admitted. As a result, acute hospital based imaging will become more specialised and with the miniaturisation and mobility of technologies many imaging and diagnostic modalities will be devolved to the primary care sector, taken to the patient using hand held devices or delivered through “bed-less” ambulatory care centres. (Rostenberg 2006; Francis et al, 2001). With the medical imaging and diagnostic technologies becoming portable, clinical models of care are likely to change encouraging a culture of screening and prevention rather than diagnosing and treating (Francis et al, 2001).
Therefore inadequate consideration of medical equipment, particularly medical imaging and diagnostic technologies, from the business case to the design brief could leave healthcare projects over budget, inflexible not fit for purpose and unsustainable.
In its most basic form inadequate briefing of equipment for large projects procured through private partnership arrangements can lead to Trusts retaining more risk than anticipated, reducing the scope of the medical equipment, or taking equipment out of the project completely. (DOH, 2004)
From the authors’ experience, one of the most common themes of a post project review of a new facility, regardless of specialty or care level, is a lack of future planning or inherent flexibility for medical equipment technology change or obsolescence. As previously described the pace of change in medical technology is rapid, however in contrast, architecture is a much slower and more deliberate process. It seems unlikely that the development of building sciences will ever be able to keep up with the pace of medical sciences. (Rostenberg 2006). Although many healthcare buildings are designed to be extended in the future, the designers often overlook how clinical space could be adapted to incorporate new technology or clinical practice.
Equally, the question of how equipment, particularly medical imaging and diagnostic technologies will be replaced at the end of their life cycle is not often answered in the design of the building. Many items of medical imaging and diagnostic equipment such as Linear Accelerators, Ultrasound, MRI and CT Scanners require significant building works including the removal of walls and ceilings to allow the removal and replacement. With such major works required, hospital trusts must face a difficult management conundrum when planning continuity of services.
An anecdotal complaint from design teams currently designing hospital projects in the UK is that essentially future-proofing or the preparedness of the buildings to adapt to new technology or replace obsolete equipment is overlooked, in the main, because it was not part of the clients brief for the facility or indeed the outline business case for the project. At best the leading technology of today is considered at the time the design is created, but paradoxically the technology of the future is somewhat forgotten.
Many would counter this view and argue the words “future proofed” or “flexibility” are often found in client briefing documents, however these statements have little meaning when not reinforced by a strategic understanding of how this can be achieved and the associated cost impact, which so often has not been considered at the business case stage. The building design needs to have the capability to embrace new technology in reality, as opposed to just making it a lifeless or immeasurable requirement in an output specification, as the consequences of not doing so ultimately could prove the whole project be judged a failure in the long term.
Guidance on Equipment in NHS Private Finance Initiative (PFI) projects, published by the Construction Industry Board (CIB) and the Department of Health (DOH) in March 2005 (revised in February 2007) stated that a number of projects where equipment had not been considered until very late in the project had caused a risk to the Trust that was “quite obviously far from ideal.”
The same paper goes on to explain that the problems faced by Trusts are due to the fact that equipment is not given early enough consideration within the briefing process. In addition, if the cost allowance for equipment within the Outline Business Case model is not detailed enough it can lead to immediate inconsistencies between the brief and the designers’ proposals, resulting in affordability problems for the whole project.
It is typical for the cost of equipment to equal as much as 30% of the project investment, so the importance of focusing on this area during the briefing phase is clear.
The operating framework for the NHS in England 2010/11 (DOH, 2009) the white paper: NHS 2010–2015: from good to great (DOH, 20009) and the Chancellor’s Pre-Budget Report (HM Treasury, 2009) were all published in December 2009 and state that £15bn-£20bn of "efficiency savings" need to be found in within the NHS between 2011 and 2014. The white paper, NHS 2010–2015: from good to great, sets out the direction for the NHS over the next five years. It outlines a plan to build on Lord Darzi’s Next Stage Review, with a strong stress on services becoming more productive including service reconfiguration and changes to clinical pathways.
Movement of services to different settings such as the community is likely to test the inherent flexibility and adaptability of the current NHS Estate and in tandem kick-start an increase in refurbishing/reusing existing NHS facilities.
The briefing of new projects in the health sector, be it refurbishment, reuse or a new hospital development, are likely to be scrutinised more than ever before. Designs and plans will need to drive through efficiency and flexibility into the estate. Equipment and technology will have a significant role in this process, perhaps more so given the challenges of adapting an estate to current and future technology (which itself might bring efficiency), and the overwhelming demand to re-use and transfer medical equipment without service interruption.
1.2 The Research – Locus, Focus and Aims
The aim of this research will be to investigate how the more complex medical imaging, diagnostic and treatment technologies are considered during the briefing phase of acute facility project and to analyse if the methods, processes, guidance, tools and techniques used by acute hospital trusts and design teams are sufficient to allow the built environment to meet the evolving needs of the NHS.
The research will focus on medical imaging and diagnostic equipment such as Radiography, MRI and CT Scanners as these particular types of equipment represent the fastest changing technology modality and equally have the biggest potential impact on the design, structure and flexibility of the built environment in both the primary secondary and tertiary care arenas.
The research will focus on the briefing of facilities on acute healthcare sites over the past 10 years, although it is expected that many of the themes will have a strong resonance across the whole healthcare spectrum.
The research will aim to test a hypothesis that equipment is often overlooked in the briefing of acute facility projects which ultimately leads to inefficient and inflexibly buildings which are not designed to adapt to new equipment, changes in technology, replacement or obsolescence of equipment or ultimately the transference and linking of equipment to offsite primary care or community based estate. The outcome of the research is to produce a good practice roadmap or toolkit to be used by hospital planning teams to support the development of the equipment brief in new healthcare projects be it new or refurbished estate.
1.3 Research Objectives and Approach
It is intended that the empirical work will be researched utilising a mixture of desktop research, literature reviews, interviews, surveys and case studies.
The diagram below (Fig 1.0) summarises the intended research approach.
Fig 1.0 – Research Approach
The following objectives and approach will be used:
1.3.1 Objective One
To investigate the key challenges that medical imaging equipment can pose to new acute facility projects.
Research Approach / Methodology / Expected Outcome
In the form of a literature review, undertake a comprehensive analysis of the available literature surrounding how medical imaging technologies relate to the built environment and vice versa. The review will focus on the effects of technology change and future trends in clinical practice which might impact on the built environment. This research objective will also encompass a series of semi-structured interviews with clinical experts and leading manufacturers of medical imaging and diagnostic equipment. An interview schedule will be developed utilising MARU Alumni, key personnel noted within the literature review and personal contacts within the industry. An outline framework of the key themes will be developed to support easier analysis of the results; however additional comments sheets will be created to record comments outside of the framework. Interviews will be audio taped if permission is granted by the interviewee. The anticipated outcome will be to provide key themes which need to be considered when developing a brief for an acute facility project.
1.3.2 Objective Two
To investigate where medical imaging technologies currently fit in the healthcare capital planning process for acute facilities and if this has changed since the introduction of the Private Finance Initiative (PFI) in 1995.
Research Approach / Methodology / Expected Outcome
In the form of a literature review, undertake a comprehensive analysis of the available literature on the UK Government capital investment process for healthcare. The review will focus on Department of Health and other UK Government guidance on the subject as well as any relevant published articles. This research objective will also encompass a series of semi-structured interviews with key personnel within the Department of Health and NHS leaders to understand how this specific area of briefing is centrally reviewed, controlled and updated, as well as any proposed future developments. An outline framework of the key themes will be developed to support easier analysis of the results; however additional comments sheets will be created to record comments outside of the framework. Interviews will be audio taped if permission is granted by the interviewee. The expected outcome is to gain an understanding of where medical equipment currently fits in the current healthcare capital planning process for acute hospitals and how this might relate to the themes identified in objective 1. The historical research of the process prior to 1995 may uncover previous good practice or methodologies which positively support the inclusion of medical equipment in the briefing set
1.3.3 Objective Three
To investigate the current tools, techniques and approaches to healthcare briefing in relationship to medical imaging technologies, as well as the available guidance and statutory regulations which need to be considered.
Approach / Methodology / Expected Outcome
In the form of a literature review, undertake a comprehensive analysis of the available literature on UK Government methodologies, tools, central guidance and legislative requirements. This research objective will also encompass a questionnaire which will be issued to a cross section of public and private experts from Hospital Trust Capital Planning Teams, Healthcare Planners, Equipment Consultants and Architects in the UK to understand the industry approach to briefing and interpretation of a brief for medical equipment. A questionnaire recipient schedule will be developed utilising MARU Alumni, key personnel noted within the literature review and personal contacts within the industry. An outline framework of the key responses and themes will be developed to support easier analysis of the results; however additional comments sheets will be supplied to record comments outside of the framework. It is anticipated that utilising a mixture of these two approaches will draw together a review of the practicing team’s use of the UK Government prescribed approach and/or if the tools and techniques provided are relied upon, sufficient or have been adapted to suit the requirements of the teams themselves or the healthcare buildings they are briefing. It is hoped that from this qualitative approach will provide examples of best practice and recommendations to develop a requirements capture and good practice framework document.
1.3.4 Objective Four
To appraise if different building procurement routes have an effect on the principle of briefing medical imaging technologies for an acute facility.
Approach / Methodology / Expected Outcome
Undertake a series of case studies of recently completed projects utilising four different building procurement types including Procure 21, PFI, PPP and Traditional build. Through a detailed appraisal of each case study, the research will look to determine the impact medical imaging and diagnostic technologies has had on the brief, design and completed built environment, as well as determining how technology change can or perhaps already has been accommodated. Working closely with the teams involved in the projects, semi structured interviews will again be applied. The interviews will be aimed at a cross section of disciplines, from client side leaders, designers, engineers, construction and procurement teams. Again an outline framework of the key themes will be developed to support easier analysis of the results; and additional comments sheets will be created to record comments outside of the framework. It is anticipated the analysis will also provide an insight into the quality of the briefing information and how that brief was translated into design and the final building by the design team and contractor. It is anticipated that through the structured interviews, details of the tools and techniques used to manage the equipment brief and the equipment budget will be appraised and a quantitative analysis of the original capital cost model for equipment and the final “as built” capital cost model for equipment will be evaluated if this is made available by the project teams. Finally it is hoped that lessons learnt from these projects, mixed with the results of the previous objective will provide recommendations for future projects. A combination of qualitative and quantitative approach will be applied to this objective.
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