The past decade has seen a major restructuring of the American health care system, with alliances among providers to heighten efficiency and create economies of scale, and smaller facilities forced to transform themselves to survive in the competitive environment. At the same time, hospitals and medical centers have watched their operating costs rise steadily. To maintain access to health care for as many people as possible, facilities are faced with the challenge of increasing productivity while reducing costs.
A key element in health care facilities today is the wide range of mechanical-electrical systems essential to their operations. In addition to the standard lighting, heating, cooling, ventilating and life safety systems, hospitals also require a variety of information systems, such as medical records databases, and specialized systems, such as air pressure and humidity control in critical areas. Therefore, energy use accounts for a significant portion of operating costs. Part of the challenge in cutting costs lies in improving equipment performance and reducing energy consumption without diminishing the comfort, safety or security of the health care environment.
Optimizing the efficiency of the mechanical-electrical systems is one approach to the problem. Accomplishing this has resulted in a greater degree of system automation and sparked the need for increased system integration. Now and in the future, the demand for improved performance and lower operating costs will accelerate hospitals’ requirements for state-of-the-art technology. All systems will have to be automated, and operating and control systems will have to be able to interface with medical systems. To make this possible, health care facilities will increasingly need a high-speed communication infrastructure.
A mechanical-electrical design template that provides for the newest technology using open protocol communications will allow various systems to be integrated while lowering overall operating costs. Such a design allows for interaction among the equipment of multiple manufacturers and for the global monitoring of all critical functions at several different locations within a facility, ensuring that systems will operate as efficiently as possible and alerting operations staff to problems as soon as they occur. This enables staff to be proactive in case of malfunctions.
The first step in this process is to identify the systems that may be candidates for integration. These might include any that operate within the health care environment — from lighting to elevators, from ventilation, heating and cooling to electrical and emergency power systems, and from laboratories to critical care systems, life safety, security and data centers.
In the past, each of these systems functioned independently. Now, all can be primed for integration. However, it may not be practical to link them all. From an engineering viewpoint, certain groups should remain separate because a change in one area is not likely to affect another — a drop in pressure in an isolation room, for example, doesn’t impact on hospital security — but certain information can still be shared among them.
Once it has been determined which systems to integrate, facility executives should decide on the strategies to optimize system interoperability. This process includes defining and itemizing specific point information for key groups, to identify what information is to be shared — what is essential to each system facility operator and what is extraneous. Not everyone will need every piece of information to operate efficiently.
Monitoring of systems is another key decision to the integration process. Utilities can be metered and submetered, for example, to determine performance levels. In addition, how facility executives will use the integration scheme to distribute energy costs properly should also be established. The design should allow for the partitioning of systems to attribute the correct costs to the various users and distribute the overhead across different branches of the hospital’s operations. To make the integrated system function at its best, each of the components can be monitored for increased control and for gauging efficiency of each piece of equipment.
For successful implementation of system integration, a series of steps should be followed. A world-class health care facility requires internal and external resources. Facility executives should first seek corporate support of the concept. That might mean going to the board of trustees to get them to buy into both the goal of sharing system technology and the methodology to achieve it and to back the program with funding.
A system integration engineer with expertise in the design of health care facilities should be engaged to consult on and develop the design. It is also essential to determine the performance requirements — that is, what the facility wants to obtain — for each system, as well as the overall performance level desired from system integration.
Next, the optimum communication protocol must be identified. Two chief standards established and widely used within the building automation industry are BACnet and LonWorks. BACnet — Building Automation Control Network — was developed to meet open protocol standards set by the American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) and is currently used by many equipment manufacturers.
LonWorks, developed independently by the Echelon Corporation, is a protocol based on a neuron chip. Each piece of equipment installed in a facility contains a chip that carries its characteristics and is able to communicate with the corresponding software in the automation system. Both protocols can be used in conjunction with the communication protocol TCP/IP.
TCP/IP — Transmission Control Protocol/Internet Protocol — is a communications protocol that binds everything on the Internet. Along with an Ethernet communication cabling plant, it ensures that any building designed today will be ready for the Internet-based technologies of the future. This protocol is incorporated into the design of the building’s infrastructure and permits communication between systems not only locally, within the building, but also over the Internet. It is especially desirable when dealing with multiple facilities. TCP/IP will allow for the facility to take advantage of all new developments occurring in research and Web-based technology.
The final step in implementing integration is to create a testing protocol to ensure that all systems slated for integration are functioning as intended within the environment. Written documentation should be developed to set procedures for testing, commissioning and project closeout once the integration has occurred. In addition, a training program should be established for all operating personnel.
The ultimate objective is to create paperless systems for the hospitals of the future. All building systems will communicate seamlessly with the building control system.
In the past, each system in a facility operated on its own network. Now, building automation engineers are designing these systems around the structured cable plant used for communications. Thus, rather than using dedicated wires, each system will be able to tap into the network already installed and operated by the information technology group.
Opportunities for system automation integration can be designed into new buildings or retrofit into older ones, taking into account the age of existing equipment and calculating the cost-benefit ratio. In considering systems integration, think in terms of installing a system with a long life. The infrastructure of the communication path should have the capability for intercommunication that will allow it to take advantage of cutting-edge technology, even if a facility’s current equipment is less advanced. Because health care facilities must remain alert to productivity and operating costs, each investment must have future value.
Carlos Petty is an associate partner and group manager in the New York City office of Syska Hennessy Group, a consulting, engineering, technology and construction firm that provides technical solutions in such areas as building automation system design, facilities management, energy management, life safety, technology consulting/engineering, and turnkey design/build services.
An example of the degree to which system integration can extend can be found in the new 290,000-square-foot children's hospital and trauma center at the Westchester Medical Center in Valhalla, N.Y. Syska Hennessey Group, in association with the architects NBBJ and Lothrop Associates, is working on the design of the mechanical, electrical, plumbing, fire protection and environmental systems for the new facility. The design will be based on a template that calls for an open protocol system using BACnet riding on a TCP/IP Ethernet backbone.
The system will integrate lighting control and electronic variable air volume boxes and provide calculations of energy use for the chiller plant to promote energy conservation. Specialized hospital systems, such as those for oxygen detection in the MRI area, pressure monitoring in isolation rooms, and temperature, humidity and pressure control in operating and recovery rooms, will report to the central building management system and interface with the fire safety system to provide for smoke exhaust. In addition, all major electrical and utility systems, as well as the back-up power supply, will be monitored and metered.
Although it was possible to tie in the security network as well, the engineers chose to maintain it as a separate system. The design template allows for even greater integration in the future as required. This facility can be viewed as a model of the current trends in design for integrating automated systems.
Property management firms that want to make the move from office to medical facilities need to understand the substantial differences between the two types of space — and then see beyond those differences.
It’s easy for Mike Krivonak, vice president and director of the health care practice at Colliers Turley Martin Tucker, to tick off a lengthy list of differences between commercial office and medical space, from more visitors to special medical waste disposal and special exhaust requirements. But Krivonak says one top priority is the same in the two markets: cost control.
“That’s one of the main objectives of all owners,” he says. “Outsourcing is not new to hospitals. They do it in other areas. Most of the time they’re looking to find cost savings.”
Colliers Turley Martin Tucker manages 1.5 million square feet of health care space, most of it in the Midwest.
Some of the best places to find savings can be found in the differences between office and medical space. For example, the 7-by-24 nature of hospital operations is both a challenge and an opportunity. “The length of operating hours is a burden on the building systems,” says Krivonak. “You have to find things to offset those costs.”
Keeping operating costs down might mean controlling start-up and shut-down times, adopting load-shedding strategies or installing variable frequency drives.
“There are a lot of basics of property management that should be employed in these facilities,” says Krivonak.
It’s not only on the tactical level that the property management firm can become involved in the health care organization’s real estate program. In some cases, the management firm may get involved in larger real estate issues, ranging from development to disposition. For example, in the development process, the property firm may provide rent modeling or even join the design team.
Getting to this strategic level takes time, says Krivonak. “The longer you’ve been with a client, the more trust you’ve developed, and the more they’re inclined to get you involved in strategic issues.”
But a long-term relationship will never have a chance to develop if the property management firm doesn’t pay close attention to the unique nature of the health care business. A good example is the relationship between the health care organization and the physicians who are its tenants.
“In a traditional landlord-tenant relationship, you have someone seeking space and someone who has space, and that’s the only relationship those two parties have,” says Krivonak. But in the health care arena, that’s only one part of a complex set of business and regulatory ties.
That relationship has an impact on the way a property is managed. “It’s important that customer service be to the highest degree, particularly response time,” says Krivonak. “You always want to provide the best service you can. But this extra relationship really keeps you focused on service.”
Lean economic times require facility executives to do more than wield sharp pencils. This is especially true in the heavily regulated industry of health care facilities, where successfully completing capital projects is as much art as science.
Tom Olson, director of construction and renovation for the north region for Advocate Health Care, the largest not-for-profit health care organization in metropolitan Chicago, is responsible for two campuses totalling nearly 1.5 million square feet.
In an almost constant state of building and renovating facilities, Olson says that in the world of health care facilities, timing is everything.
“Our state’s Department of Public Health has to review and inspect all paperwork and construction before it signs off on it,” he says. “The problem is that the department is understaffed, and getting the inspection to happen in a timely manner means every supplier and contractor down the line has to hit target dates.” Planning that schedule and making it happen is a full-time job in itself, he says.
Olson is currently completing a $14 million project that was staged over four years. It’s about 80 percent paid out. The hospital is planning a new emergency room facility at about $10 million. There also are studies for new operating rooms and possibly a new ambulatory care building at about $20 million.
Successfully completing these projects will be increasingly tricky given shrinking budgets.
“Reimbursements are down from insurance companies, Medicare and Medicaid,” Olson says. “We have trimmed all the fat and are beginning to cut into muscle.”