Building the Hospital of 2046:
Five Challenges That Affect Specifications

By: Maureen P. Taylor

Reprinted from May 2006 ohioconstructionlaw.com

Highlights. There’s a construction boom in healthcare, and the hospitals being built in 2006 need to serve the population 40 or 50 years into the future. What will patient care require at mid-century? Which medical procedures will remain the same, and which will use equipment and techniques not even dreamed of today? For anyone interested in healthcare construction, building for change is crucial. Still, there are some constants, some trends that keep surfacing in the literature and the discussions when healthcare administrators meet. This article looks at five related emphases we expect to see in the plans and specifications for hospital construction in the immediate future: (1) Patient safety, (2) Emergency preparedness, (3) Commissioning, (4) Sustainability, and (5) Research-Based construction.

The Challenge for Hospital Construction

Where is a good crystal ball when you need one? Anyone working on hospital construction today would have to admit that an accurate predictor of the future would come in really handy when the design team tries to foresee the kind of hospital it will need 30, 40 or 50 years in the future.

Thinking about the changes in healthcare delivery since 1966 can provide an inkling of what may lie ahead in the next 40 years. The needs of the hospital of 2046 can be as different from today’s needs as today’s needs are different from those in 1966. Still, hospitals must be built now, and they must accommodate future needs. Waiting until the future is here is not an option.

Even without a crystal ball, the construction industry and healthcare professionals, working together, have focused their plans on five emphases that look positive for the hospital of 2046. Here are the trends, as we see them from reviewing the literature and talking to those in the industry:

Patient Safety

Taking a cue from the automotive and aerospace industry, hospital planners are working to improve safety for their “customers.” Motivated by increasing premiums for malpractice insurance and by reports of perhaps as many as 99,000 deaths in one year (1999) caused by medical mistakes, they are asking their architects to design a safer hospital, as mistake-free as possible.

Some of the improvements in plans and specifications are obvious: consistent lighting to simulate natural light, improving the quality of visual diagnoses; floors that are slip-proof, reducing falls; improved ventilation, even to the point of eliminating recycled air, reducing the spread of infection; and better visibility, making it possible for nurses to see all their patients from the nurses’ station.

Others are less intuitive but make sense on further thought. For instance, standardization is key in some of the newer hospitals. In St. Joseph’s Hospital in West Bend, Wisconsin, recently profiled in The Wall Street Journal, every room in the 80-bed facility is identical to every other room. Why? Then doctors and nurses know exactly where to find equipment they may need in a hurry. The aim was to make the surroundings as familiar to the professionals working there as a cockpit is to an airline pilot. Uniformity helped to achieve that goal. Standardization also helped with the construction budget, as the hospital could buy in bulk from vendors who offered discounts.

The move away from double-occupancy rooms is another aspect of the focus on patient safety. Individual rooms reduce the risk of infections and lower patient stress, both making for a safer, more pleasant hospital stay. The single rooms are also larger than in the past, permitting increased family visits and allowing more flexibility for equipment and procedures yet to be developed. Predictions that the wireless infrastructure will permit point-of-care testing and other services to “come to the patient” depend on the larger rooms, too.

Emergency Preparedness

Hurricane Katrina was a wakeup call for many hospital planners. Back-up generators stopped working, and communications with other healthcare centers were often non-existent. Hospitals dependent on electronic medical records struggled to access them.

The huge influx of patients needing emergency care overwhelmed some hospitals, causing them to close. One hospital—Ochsner Clinic Foundation in New Orleans—found an innovative if old-fashioned way to let the rest of the world know it was still open for patients: spelling out “open” on the hospital roof by spreading out large trash bags.

The need for better planning is obvious, but the solution is less so. As a first step toward rectifying that problem, Skanska USA Building Inc. conducted a University Grant Competition, awarding a $5,000 prize to the team of student architects with the best solution for upgrading health facilities in New Orleans.

The winning team, four women who are all seniors in the College of Architecture at Texas A&M, submitted a two-stage design. Its long-range plan was for replacing the existing Charity Hospital, devastated by the hurricane, and included larger emergency facilities. But the team also presented a short-range plan for modular clinics throughout the city. These would operate in the immediate future to replace the hospital during the reconstruction, and after that they would continue to supplement hospital services, helping to decrease patient overload.

It is still early to say exactly how hospital plans and specifications will change as a result of Katrina’s impact on healthcare in New Orleans. But it is safe to say that future hospital planners will give even more thought to maintaining access to electronic records, to keeping communication channels open to other hospitals and to government authorities, and to preparing for large increases in the population of emergency room patients on very little notice.

Of course, natural disasters are not the only emergencies hospitals need to prepare for. In the twenty-first century, anyone planning a hospital must consider how the facility might respond to possible terrorist attacks. Some consult terrorism experts to evaluate their plans. For instance, the new children’s and women’s hospital in the University of Michigan Health System in Ann Arbor has eliminated any recycling of air in patient rooms—a step taken to increase patient safety, as discussed above. But the unusual design has a positive side effect: the consequence of a biological or chemical outbreak could be confined to one room, according to the terrorism expert the hospital consulted.

Commissioning

Commissioning is “the process of ensuring that systems are designed, installed, functionally tested, and capable of being operated and maintained to perform in conformity with the design intent.” That standard definition comes from the American Society of Heating, Refrigeration and Air-Conditioning Engineers, Inc., otherwise known as ASHRAE. For a general discussion of commissioning, see Commissioning—Is It the Answer to HVAC Problems? from July 2003.

Although commissioning started as a way to test and assure that a building’s mechanical systems were working as intended, the concept has spread to other systems. In a hospital there are numerous high-tech systems that do not even exist in many other buildings, and they all benefit from commissioning. Tony Furst, LEED AP, Senior Project Administrator for Commissioning Services with Heapy Engineering, Inc., sums up the major hospital systems for commissioning this way:

• All medical gas systems;

• Life safety systems, such as fire alarms and sprinklers;

• Room pressurization controls;

• Paging systems;

• Laboratory equipment, such as fume hoods and biohazard controls;

• Generators;

• Emergency lighting; and

• Airflow controls.

In a hospital setting, commissioning is more in-depth than in other buildings, according to Furst. If a hospital seeks LEED certification, commissioning of the fundamental building systems is a prerequisite. (LEED stands for Leadership in Energy and Environmental Design; the accompanying article on “Green Buildings & Green Hospitals—Earning ‘Points’ for Being Energy Efficient” explores what this certification means.) Additional commissioning—beyond the fundamental building systems—can earn a hospital additional credit toward certification.

How can a hospital find a Commissioning Authority? The procedure, Furst says, involves issuing a Request for Qualifications, followed by in-depth interviews of the promising candidates. Interview questions should probe the company’s experience with hospital commissioning and the backgrounds of the particular personnel who would be assigned to the project. Getting the Commissioning Authority on board at an early stage of the design process is essential, Furst thinks, if a hospital is to see the most benefits.

What are the benefits of commissioning? Troubleshooting is a major skill for those involved in commissioning, a skill that helps to keep the project on schedule. Another real benefit is establishing warranty dates, as it is very clear when particular equipment was placed in service. Additionally, the Commissioning Authority can assure that contractors provide adequate training to the hospital maintenance staff, in compliance with the contract. Such training is needed to be sure the high-tech equipment that is operating as designed when the hospital opens continues to operate at an optimal level.

Sustainability

Closely linked to the topic of commissioning is the issue of sustainability, another hot topic in hospital construction today. What is sustainability? According to the World Commission on Environment and Development, sustainability is the ability of development “to meet the needs of the present without compromising the ability of future generations to meet their own needs.” The focus is on energy use, the environment of the building as a healthy place for workers and patients, and the effect on the wider environment of the products and procedures that go into the building’s construction.

Requirements for sustainability have been appearing recently in Requests for Proposals for hospital design, according to David Norris, Project Manager and Principal of The Design Group. Although a hospital may not be seeking LEED certification, it may still want to consider elements of that certification and to incorporate any that will be beneficial to the bottom line.

One RFP that Norris noted included a requirement for a “charette for sustainability” to be incorporated early in the design process. (If “charette” is a new word for you—it was for me—Google defines a design charette as “an urban planning technique for consulting with all stakeholders.” It involves an intense, lengthy meeting designed to resolve an issue and obtain joint ownership of the resolution.)

Norris thinks that the greater emphasis on sustainability results in part from increased governmental regulation. For instance, the Ohio General Assembly is currently considering House Bill 467, which would require any state building or school being constructed or renovated to be “designed and maintained in accordance with LEED energy efficiency and design standards.” Most hospitals are not yet affected by such regulations, but the movement is out there.

Research-Based Construction

The one trend that ties together all of the trends we have seen so far is research. Hospital planners want to base their designs on something concrete and verifiable, “evidence-based design,” as the Center for Health Design puts it. According to the definition on the group’s website, www.healthdesign.org, “an evidence-based healthcare design should result in demonstrated improvements in the organization’s clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures.”

The Center for Health Design is a 13-year-old organization whose mission is “to improve the quality of healthcare through building architecture and design.” Since 2000, its major research emphasis has been the Pebble Project®, designed to create a ripple effect in health care by incorporating evidence-based design into multiple projects.

Currently, there are 35 hospitals involved, including four in Ohio: Cincinnati Children’s Hospital Medical Center, Community Mercy Health Partners in Springfield, Dublin Methodist Hospital, and the Lake Hospital System in Lake County. The hospitals agree to conduct research on the effects of various design aspects on the patients and staff, publishing their findings regardless of the results. Early results from some of the projects can be found online.

Another project of the Center for Health Design is reviewing the published literature on research related to hospital design. It recently published a review of some 600 studies, concluding that there was “a direct link between patient health and quality of care and the way a hospital is designed.” That report, entitled “The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity,” can be ordered on the organization’s website.

What’s Next?

From the amount of hospital construction and renovation going on today, it is clear that over the next five to ten years, many new facilities will be opening their doors. Those who want to study the effects of particular design choices should have ample opportunity. These studies will undoubtedly lead to new trends in hospital construction. So, if you’re still reading us in the year 2046, look for an update predicting the emphases that will be important as architects, contractors, and hospital administrators plan for the hospital of 2086.