Specifics and limitations of healthcare buildings

Introduction

A modern hospital is not just a complex of various gray-white buildings. In this case, it can be compared to a living organism that is constantly evolving and flourishing, or suffering and dying. We could imagine the complexity of a healthcare facility as a creature with a heart that beats regardless of day or night. It has arteries that supply the hospital with energy and materials and distribute them throughout the complex. It has a spine that serves as a pathway for patients and employees. It has individual organs, each of which has its own purpose, location, and connection to the others. Given that it is very difficult to produce truly high-quality project documentation for these buildings, it is essential to have a number of experienced specialists and a large team of collaborators, not only from among designers.

In the history of healthcare facility design to date, we most often encounter the following types of tasks:

■ modernization/reconstruction of hospital premises in stages while in operation;

■ designing a development concept/master plan/structural plan for the hospital;

■ construction of new, dominant pavilions that will significantly affect operations throughout the complex;

■ modernization, reconstruction, or extension of a pavilion/wing while the complex remains in operation;

■ modernization/reconstruction of a department while the pavilion remains in operation.

Specifics of healthcare buildings

Healthcare buildings are among the most complex projects. Whether it is meeting construction requirements or organizational arrangements, continuity and interconnection of individual departments and links. And it does not have to be entire hospital wards or healthcare centers. Even relatively small buildings, such as pharmacies, must meet strict hygiene requirements for clean spaces. Smaller-scale construction or partial renovation of facilities with imaging technology can also have very specific structural and technical requirements.

A different approach is applied to healthcare buildings than, for example, to the construction of shopping centers, which are built primarily to meet the needs of customers and retailers. They also differ from administrative and industrial buildings, which are designed to provide an efficient environment for work and production. There are also significant differences from residential buildings, civic amenities, and sports facilities.

The requirements for healthcare facilities reflect the interests of the founder, who invests considerable funds in them, the future operator, and the professional staff who will perform demanding and skilled work in them, for which they need suitable conditions. Also factored in are the needs of patients, who arrive at the hospital during a period of personal distress and whose treatment is influenced not only by professional care but also by the quality of the environment in which it is provided.

The longevity of healthcare buildings

In addition, the lifespan of buildings is designed to be between fifty and one hundred years. Healthcare facilities are often located in historic, sometimes centuries-old buildings, but the technological equipment using modern techniques and accompanying developments in medical science changes every few years. We cannot overlook the parameters of construction efficiency, operating economics, and the correct requirements of "green" legislation with the aim of reducing operating costs, energy consumption, and the environmental impact of operations.

Legal regulations

The requirements for the structural and technical design of healthcare buildings are defined by decrees issued by the Ministry of Health. Legal regulations are not keeping pace with developments; although they change frequently, they are incomplete as a whole and do not reflect the complexity of the entire system of processes, flows, and the specific environment of individual workplaces. When preparing a project, the decisive factors are primarily experience and good communication between designers, clients, staff, and hygiene representatives.

Project team

Cooperation on healthcare projects is a long-term process involving many partners who must form a team. This includes the client – investor, healthcare staff, technical staff, architect, designer, builder, technologist, HVAC designer, including, for example, a medical gas designer, and, last but not least, state authorities. Not only do they need to agree during the planning phase, they also need to think long-term. They cannot just address immediate costs, but also need to consider future operating costs. In such cases, there is considerable scope for using BIM to facilitate communication between all parties involved. BIM increases the availability of information for decision-making and improves control over construction processes. It also saves time and eliminates multiple changes during the preparation of project documentation. The documentation contains specific products, not just their general specifications. Once a product is selected, it is checked to ensure that it meets the necessary requirements. BIM thus reduces the costs of construction and building operation.

Development plan

A clear concept for the development of healthcare in terms of location and time at the relevant levels, represented by the Ministry of Finance and the Ministry of Health, individual regions, hospitals, and health insurance companies, is also essential for a successful project. Another factor is the outlook for the development of healthcare fields and healthcare technology and the resulting requirements of the contracting authority. It is desirable for founders to have a conceptual plan for the status and proposal for the sustainable development of hospitals. The planning of new projects would then be more systematic and would take into account both the economic and professional aspects of the construction of new and renovation of existing healthcare facilities.

Limiting factors in healthcare construction

The following factors limit the development of healthcare construction projects:

■ Limited financial resources. For this reason, with a few exceptions (Zlín), the construction of new hospital complexes is not currently planned, but rather the gradual reconstruction and extension of existing complexes.

■ A significant complication is the often limited space available in existing hospital complexes. There is not enough free space to build new pavilions, demolition is costly, and so repairs and construction work are forced to take place while the complex is in operation, which adversely affects healthcare operations.

■ Modernization during operation is always uncomfortable for patients, especially those who are hospitalized. In addition, it requires considerable tolerance from medical staff and operational employees.

■ These are often public contracts, where any change in the assignment during the preparation of the plan and the construction itself is de facto unacceptable, even if it would be beneficial to the project.

In general, it can be said that the design of a new healthcare facility or the development of an existing complex is always a set of activities based primarily on the zoning plan of the settlement and the general plan of the hospital, the facility itself as a whole, and its focus. The first step is to define and characterize the area in question, the limits of land use, and the protection zones in the given area. The history of the facility, the composition of the workplaces, their interconnection, the condition of individual buildings and operations, and the evaluation of programs and plans play an important role.

Evaluation of the concept

Before submitting a specific proposal, it is necessary to evaluate and implement the concept of operational links and assess their usefulness and effectiveness. It is important to assess the technical condition of the existing building stock and to create an overview of its current capacity. It is also essential not to neglect to carry out a comprehensive survey and to use this to identify shortcomings and the scope of the future solution and to propose its phasing. This evaluation should focus primarily on the healthcare operation itself and the possible training of new healthcare professionals and doctors. It must also include transport and communication solutions, economic facilities, and the construction process. It should also focus on the preservation of historical monuments within the complex, and it is also necessary to cooperate with the wider context of the surrounding area and include a concept for greenery. The impact of healthcare buildings on the environment, both during construction and use, cannot be overlooked.

This is followed by an analysis of the technical infrastructure, where it is necessary to deal with the economic components. Another priority is the supply of all necessary utilities. Care must be taken to ensure that the buildings are suitably connected to off-site transport. Equally important is on-site transport and its connections. All of this is then the subject of the urban concept and operational solution for the complex, known as the master plan. Afterward, one can proceed to the design of individual buildings, or potentially hold architectural competitions or public tenders to determine their form.

The Role of the Architect

For healthcare facilities, perhaps even more so than for other building typologies, the project documentation should be developed in constant collaboration with the architect. Throughout the individual phases of the project, it is necessary to take into account its changes and evolution, which are then reflected in both the exterior appearance and the interior layout of the building. It is not possible to assume that the architect will create a volumetric study with a basic spatial arrangement of the floor plans and exterior facades, hand it over to the designer, and then not intervene further. This architectural study is transformed into a concrete form based on dialogue with the responsible medical staff, requirements for the technical layout of the building, the envelope, etc. It is necessary for the architect to participate in the entire process and further develop the solution.

Healthcare buildings have a long lifespan and are expensive to operate and purchase, so they require smart and flexible solutions. Therefore, it is necessary that the final work is the combined result of the work of both the architect and the designer, and that their participation throughout the preparation of the project and construction is also taken into account in the fees.

Structural Design of Healthcare Buildings and Materials Used

Healthcare facilities must be flexible so they can more easily adapt to changes in operational conditions: hygiene, work organization, medical-technical, quality standards, etc. Given the long service life of healthcare buildings and the high probability of renovations, a column-slab skeleton system with large spans is used for the structural systems. Building materials in healthcare must meet a number of parameters. In addition to quality, high demands are placed on hygiene and health safety, fire resistance, acoustics, and, last but not least, aesthetics.

Traffic flows on the premises and collision-free movement

As part of the project preparation, it is essential to work out the operational aspects in detail and ensure the future collision-free movement of both people and materials. It is therefore desirable from the outset to thoroughly review the design and operational content of the vertical communication routes of the individual pavilions, their connection to the departments on the floors, and possibly their connection via communication corridors to the surrounding buildings on the premises (above-ground, underground, exterior on the ground). Traffic flows within a healthcare facility are highly complex, and it is essential not to overlook any of them. These include access for outpatients, visitors, and staff. It is necessary to account for the transport of bedridden patients—both emergency and routine transport—as well as catering, supply logistics, and waste management. The safety of staff, physicians, and visitors must also be taken into consideration.

When working on such complex projects, it becomes clear that the task cannot be successfully completed without a detailed understanding of the specific site and close cooperation not only with doctors but also with the hospital's technical staff. This is especially true when each facility has its own specific characteristics, historical customs, and spatial limitations.

Workplaces with specific construction requirements

Workplaces with specific structural requirements include imaging departments such as radiology, nuclear medicine, and radiation oncology. These workplaces require special structural and construction solutions. This primarily involves protecting people from X-ray and gamma radiation. The standard solution is a reinforced concrete wall system with appropriately dimensioned flat elements, supplemented by suitable prefabricated systems with the appropriate parameters of resistance to the penetration of ionizing radiation, so as to ensure that the protected areas are shielded from the effects of radiation. Furthermore, it is necessary to consider the connections required to support high cooling and electrical power demands, along with the requirements for low-voltage safety and communication systems. Particularly in this sector, it is essential to account for transport routes for the installation and future replacement of constantly evolving medical technology.

Building Services

The building services systems in healthcare facilities are much more complex than in other buildings of similar size. In addition to standard components such as ventilation, plumbing, cooling, and heating, as well as the power plant including a backup power source, water treatment and medical gas supply are often required. Specific requirements are placed on electrical installations, grounding, and low-voltage systems. The design is greatly influenced by fire safety requirements and hygiene requirements for clean rooms.

When working on healthcare projects, 3D design really pays off. OBERMERYER HELIKA a.s. uses Revit software, which allows for detailed planning of all spaces down to the smallest detail. Based on this concept, a 3D model of the building is then created, which helps with the spatial arrangement and facilitates the layout of all planned installations.

Renovate existing facilities or build a new hospital

The decision to modernize existing healthcare facilities or build a new hospital from scratch is not an easy one for their founders. There are a number of complex economic and organizational parameters at play.

First option: renovation

The modernization and repair of existing healthcare facilities are usually prompted by the unsustainable condition of their technical equipment. For some time now, there has been a noticeable effort, or even pressure, on the part of operators or founders to raise standards for clients. Last but not least, the operational requirements of the healthcare facility operator are also a reason.

A major advantage of renovating an existing facility is the ability to choose the scope of construction work according to the amount of investment costs allocated. The disadvantages are obvious: outdated and unupdated project documentation for the existing facility, often only an estimated condition of technical equipment and furnishings, uncontrollable secondary impacts, temporary measures to maintain operations, etc.

It is important that each completed stage creates an operational whole and that each subsequent stage of construction does not interfere with operations and connects smoothly with the previous stage. This is often not the case, resulting in additional investments to ensure phasing.

New construction: if there is vacant land

New construction seems more straightforward and can be tailored to the current needs of the facility's operation, in full compliance with quality and technical standards and trends in construction development. There are no unpleasant compromises due to insufficient space. However, new construction requires land, which is often complicated to acquire and often involves the demolition of old, unsuitable buildings, which often house operations for which temporary accommodation must be found.

Differences between private and public contracts

The main difference between public contracts and private investors is the requirement of private investors for 3D design, which is expected in public contracts in the future but is not yet required. In public investments, it is therefore not possible to communicate with the contractor during the design preparation phase using a 3D model. In public procurement, it is problematic that a significant change in the project’s tender parameters is difficult to accept and usually means starting over from scratch. Minor changes are difficult to negotiate, primarily due to the link to the tender process and the rules of grant programs.

Private investment allows for fundamental changes to be addressed "on the fly," not only during the preparation of the project, but also during the construction. In a contract from a private investor, the project is modeled and, at the same time, communication with contractors is already underway, who immediately enter the construction requirements into production. Feedback comes from there, and everything is resolved operatively online. However, the project preparation and discussion processes are the same, as are the quality of the project and the construction implementation process.

An example of this solution is the planned construction of a new wing at Pelhřimov Hospital and the renovation of the Waltr building at Medicentrum. Information about these projects can be found in the next article. Another significant project on which OBERMEYER HELIKA a.s. has been working for a long time is the reconstruction of the children's ward at the Motol University Hospital. The company worked on this project continuously from 2003 to 2018. This modernization was and remains one of the largest healthcare construction projects in the Czech Republic in terms of its scope.

The importance of healthcare facilities in light of the pandemic

As in all countries around the world, the COVID-19 pandemic has been an extraordinary test for the entire healthcare system and related logistics in the Czech Republic. In general, it can be said that the Czech healthcare system has passed this spring test. The relatively good economic situation of recent years has allowed for greater investment in healthcare. In terms of construction, both the gradual renovation of hospital complexes and the construction of new wards continued in the Czech Republic. Preparations for further investments have also begun. It must be noted, however, that this does not apply to all Czech hospitals and all regions. In short, there is still a great need for more modern hospitals and polyclinics in the Czech Republic. We can say that, although the long-term transformation of the Czech healthcare system has had a number of partial successes, let us believe together that it will not stop there. And if we are to be prepared for pandemics similar to the current one, it is necessary to continue investing in the modernization of Czech healthcare capacities. We simply cannot afford any other scenario: the Czech public relies on its top-quality healthcare system. The reconstruction and completion of existing buildings will continue to be a major and important requirement for architects and designers in the future.

Published at Stavebnictví magazine on 31st August, 2020

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