While no healthcare construction project can really be classified as “easy,” renovations of existing, operational facilities tend to come with the most challenges, from patient safety to infection control to maintaining desired census. Over recent years, firms have reported significant growth in renovations, as hospitals and health systems across the country bypass costlier new construction projects in favor of remodels.

And this challenging project type is primed for even more growth. Bracing for the effects of healthcare reform, facilities are rethinking space plans to support both an expanded patient population and a push toward patient-centered care.

Superintendents at Hoar Construction (Birmingham, Ala.) decided to delve into the complexities of these projects and figure out what steps can alleviate some of their inherent challenges. The resulting white paper, “A Four-Point Plan to Streamline and Simplify Healthcare Renovation Projects,” explores some of the best practices that emerged from the company’s millions of square feet of renovation work (To read the white paper, please see the PDF in the attachment area below).

Focus on the patient
The Hoar team first stresses a basic truth that can’t be overlooked: Patients will be using the facility under construction. And with patient satisfaction now tied to reimbursements, maintaining a happy population is even more highly valued by facility owners.

To this end, Eddie Hyde, construction superintendent with Hoar, says communication is key to making sure not only patients but staff are prepared for disruptions. For example, report that project “X” is taking place on a certain day and encourage feedback on whether the work becomes too loud.

“We found that when we do that, their tolerance for noise is much better than if you don’t communicate that,” Hyde says.

While setting expectations upfront and sharing schedules are critical, letting ownership know when there’s been a change of plans is just as important. “We’re geared to want to go, go, go, and we may have to sacrifice time to back up and give ownership enough time to communicate that change and not push forward on the schedule,” says Brady Johnson, construction superintendent with Hoar’s Houston office, adding that skipping this may result in  damage to the client relationship. “It’s hard to change a perception.”

And while plenty needs to be communicated to the facility by the project team, there’s information that ownership must provide, as well. Hyde says he’s interested in garnering an understanding of how flexible an owner is—whether changes require a one-hour or three-day notice, or what the expectations are for infection control, noise, disruptions to operations, etc. Outside of monthly owner/architect/contractor meetings, Hoar encourages superintendents to meet with facility managers weekly, if not daily. “[Monthly] is not enough when you’re working in an active hospital that never shuts down,” Hyde says.

Begin at the end
Oftentimes on renovations, when construction is completed on one piece of the property, operations move into that space and out of another that’s next on the work list. Successful implementation of this process requires plenty of scheduling, sequencing, and phasing. Johnson urges project teams to consider what areas of the hospital are being renovated when planning how best to proceed.

For example, he says, phasing of an emergency department project may be different than in a central plant. “It’s so critical to make sure you understand the facility’s flows and needs so you can schedule it the right way with the least impact possible,” he says.

Phasing also plays a role from a business perspective—when a 100,000-square-foot facility is renovated in phases, each phase reduces the amount of space the facility has available to deliver care. “We’re impacting the way they operate. Schedules are very important, because it’s critical we turn those areas back over to them as quickly as we can. Otherwise, we can affect the census. You don’t want doctors taking patients to other facilities,” Hyde says.

But the worst offender when it comes to pushing schedules off track is unforeseen conditions, Hyde says. Too often, poor as-built drawings or inexperienced facilities directors translate to a lot of unknowns being discovered—meaning utilities no one knew existed will have to be moved or infrastructure placed in a space the team never intended to touch.

“You have to couple that with planning,” Johnson says. “It’s having an understanding from the owner that we may need to spend some time in there to investigate, and bringing us in early to understand what’s in the walls and how it works. The problem is, sometimes we don’t have that luxury. I don’t know that you’d consider planning a hurdle, but lack of it certainly can be.”

Team with technology
While planning can help reduce the impact of unforeseen conditions, so can the use of technology—specifically, 3-D building information modeling (BIM). By demolishing an area, laser scanning a portion, placing it in a BIM model, and pinpointing the existing infrastructure, project teams are able to know precisely where something like ductwork needs to be placed to maintain ceiling heights, for example.

“We use it on every project. I can’t tell you how much time it’s saving, but I know it’s saving headaches,” Johnson says.

But beyond BIM, Hoar has found the use of mobile devices to speed communication between team members and put critical documents, like contracts and drawings, right in the hands of those who need them. The transition to this point of adoption wasn’t easy, though.

“It took a long time to convince ourselves to really look at it and say this is more of a help than a hindrance, and it will help our team get questions answered quicker and perhaps get them more time in the field because they don’t have to be next to their computer,” Johnson says.

However, the company also encourages piloting new technology initiatives to see if they can successfully be applied on job sites. For example, before moving to full adoption of iPads onsite, Hoar gave it a go for simpler tasks like storing equipment manuals and videoconferencing. “If it doesn’t make us better at our job, we’re not going to do that,” Hyde says.

Safety first
With all the proper schedules and technology in place, Hoar stresses that a successful healthcare renovation project is one that never puts patients or staff at risk. To that end, the firm encourages construction professionals to work closely with facilities staffs on infection control, discussing factors ranging from how one enters and exits the building to where dust partitions will be set up to how spaces will be placed under negative pressure.

And while many facilities will have savvy infection control practitioners and staff, as well as aggressive infection control programs in place, others may not. Hoar encourages contractors to partner with the facility and request an orientation to the program in place, while also exploring training no matter what level of understanding is in play.

The same goes for subcontractors, too. Especially in rural locales, teams hired may not have previous healthcare experience nor know about proper safeguards that should be in place.

“We try to hire the most sophisticated subcontractors that we can, but we’re going to train them either way. When it comes to infection control, that’s a big deal and we need e
veryone out there to be our eyes and ears,” Johnson says.

Jennifer Kovacs Silvis is managing editor of Healthcare Design. She can be reached at jsilvis@vendomegrp.com.

SIDEBAR: 4 keys to healthcare renovation success
Superintendents at Hoar Construction (Birmingham, Ala. ) dissected recent projects to identify four essential components to streamlining and simplifying healthcare renovation projects:

  1. Focus first on patient safety and satisfaction.
  2. Plan from the start for a successful conclusion.
  3. Leverage technology to enhance processes and outcomes.
  4. Implement extensive infection control safeguards.