Hospital spring 2013 issuu by Adbourne Publishing

VOL 36

NO 2

SEPTEMBER 2013

the australian

engineer HOSPITAL S

Platinum Partner

Gold Partners The Conference Dinner will be held on the Starship Sydney

CONFERENCE PROGRAM

CONFERENCE DINNER

This year’s Conference theme is ‘Planning for the Future’.

The Conference Dinner will be held on Conference Dinner Sponsored by the Starship Sydney, Australia’s largest and most contemporary glass cruise boat, giving all guests panoramic uninterrupted views of the harbour. Set over 3 levels with floor to ceiling glass and an open air top deck, PP 100010900 Starship Sydney offers guests a unique experience.

Innovation in Health Design

Thinking Outside the Box for Funding Keynote Speakers include: • Anders Sorman-Nilsson, AssetMark: Future Direction Futurist and Innovation Strategist •

Kathy Meleady, A/Director, Health System Planning and Investment, NSW Health

IHEA National Board of Directors National President Mitch Cadden (State Elected – NSW/ACT) National Immediate Past President Daryl Pitcher National Vice President Darren Green (Nationally Elected) National Treasurer Peter Easson (State Elected – WA) National Secretary Scott Wells (State Elected – QLD) 2013 National Conference Coordinator Brett Petherbridge (Nationally Elected) Membership Registrar Alex Mair (Nationally Elected) Standards Coordinator Trevor Sheldon(State Elected SA) Asset Mark Coordinator Mark Stokoe (Nationally Elected) CHCFM Coordinator Mark Turnham (State Elected Vic/Tas) Chief Executive Officer Jim Cozens Secretariat/Website Administrator Heidi Moon Finance/Membership Lynden Smith Editorial Committee Mitch Cadden, Daryl Pitcher, Scott Wells IHEA Mission Statement To support members and industry stakeholders to achieve best practice health engineering in sustainable public and private healthcare sectors. Adbourne Publishing 18/69 Acacia Road Ferntree Gully, VIC 3156 PO Box 735, Belgrave, VIC 3160 www.adbourne.com ADVERTISING Melbourne: Neil Muir T: (03) 9758 1433 F: (03) 9758 1432 E: neil@adbourne.com Adelaide: Robert Spowart T: 0488 390 039 E: robert@adbourne.com PRODUCTION Emily Wallis T: (03) 9758 1436 E: production@adbourne.com Administration Robyn Fantin T: (03) 9758 1431 E: admin@adbourne.com Marketing Tania Lamanna T: (03) 9500 0285 E: tlamanna@bigpond.net.au

CONTENTS

BRANCH NEWS

Message from the CEO

6 SPECIAL FEATURE: AssetMark: Future Direction 10 Vale: Chris Ford 13 State Branch Reports 14 National Conference: Technical Paper Presenter Abstracts

TECHNICAL PAPERS

24 Quieting Alarms on Floor can Pay Big Dividends 28 Planning for Efficiency 32 Fresh Air 36 Mould Exposure and Duty of Care for Hospital Facility Managers and Engineers 40 Microbiological Contamination of Potable Water System Within Critical Care Facilities 44 The Best Technology can Offer for a Hospital Hydrotherapy Pool

54 74

50 Innovation in Health Design 54 Cogeneration & Trigeneration

TOPICS OF INTEREST

60 New Report Provides Valuable Communication Tool 65 It’s Time to Think Outside the Box for Funding 66 Healthcare: Why Human Resource Practices Are Flat-lining 68 Contractor Management 74 OHS: how to plan it, fund it & get everyone onboard 78 The Next Step

84 Introduction to Operational Readiness National Conference Interactive Workshop Topic

PRODUCT NEWS

88 Product news

The views expressed in this publication are not necessarily those of the Institute of Hospital Engineering Australia or the publisher. The publisher shall not be under any liability whatsoever in respect to the contents of contributed articles. The Editor reserves the right to edit or otherwise alter articles for publication. Adbourne Publishing cannot ensure that the advertisers appearing in The Hospital Engineer comply absolutely with the Trades Practices Act and other consumer legislation. The responsibility is therefore on the person, company or advertising agency submitting the advertisement(s) for publication. Adbourne Publishing reserves the right to refuse any advertisement without stating the reason. No responsibility is accepted for incorrect information contained in advertisements or editorial. The editor reserves the right to edit, abridge or otherwise alter articles for publication. All original material produced in this magazine remains the property of the publisher and cannot be reproduced without authority. The views of the contributors and all submitted editorial are the author’s views and are not necessarily those of the publisher.

BRANCH NEWS

Message from the CEO

our Institute is entering an exciting era in terms of revitalisation of member services. The initial task has been to ensure that programming of the National Conference is in keeping with Member requirements. The program as presented has been assembled to reflect the theme â&#x20AC;&#x153;Planning for the Futureâ&#x20AC;?. The organising Committee has worked tirelessly in association with our event manager to firstly address the theme and importantly to attract commercial interest through sponsors and exhibitors to support the program and to provide technical and product information of relevance to Members. On behalf of the Board I encourage Members to avail themselves of the benefits that the National Conference provides through the technical and social programs and the information obtained from Conference Sponsors. A most exciting development is the near future on-line capability of AssetMark. From my perspective the principles of AssetMark are at leading edge in terms of Health Services Benchmarking Engineering and Facilities Management Services. The past issue has primarily been the process. This point has been acknowledged with significant consideration by the Board on how to address this issue. The resolve being through significant investment in association with Mercury Systems to transform the previous manual process to a web based on line system. A more detailed description of the on line processes is contained in an article prepared by Mark Stokoe, WA State Branch President in this edition of the Journal. The Board is looking forward to launching the on line system at the National Conference in association with Mercury Systems. The Board also anticipates Member support in taking up the system as an effective management tool and as an added value tool

for accreditation benchmarking and comparative analysis. It is proposed to promote AssetMark nationally and in New Zealand as an IHEA initiative the benefits of which will identify the IHEA as peak body regarding engineering services benchmarking capability and also to provide a revenue stream that will contribute to a broader range of member services particularly as they relate to professional development. A further Board initiative has been to explore opportunities to link with industry for the provision of training programs that support Member professional development by awarding CHCFM credits as part of the CHCFM Program. The first linkage in this regard is currently being formalised with Schneider Electrics. Schneider operate a free online Energy University as an educational resource offering more than 200 vendor-neutral courses on energy efficiency and data centre topics to assist facility managers implement and monitor efficiency improvements within their organisation. Further details regarding the IHEA linkage with Schneider Electrics will be made available in the near future and circulated to all Members accordingly. In recent times I have received considerable feedback and opinion from Members regarding the direction of the Institute most of which has been positive and some not so positive. Based on the information received the message I wish to convey is to reflect on the past primarily on achievements but importantly to look to future challenges. In this regard your Board is most certainly looking to the future with commitment and enthusiasm to plan the future that will best serve IHEA Members. Regards Jim Cozens Chief Executive Officer

SPECIAL FEATURE

AssetMark

Future Direction Mark Stokoe I MBA, Grad Dip Mgt, A Dip Eng. FIHEA, CHCFM

The use of the current AssetMark system by hospital health facilities managers and engineers has decreased to a point of no activity occurring. A number of reasons have been cited for the lack of activity including cost, time to do, slow process and level of information required. Based on the level of activity it would not be of any value to IHEA or its members to continue with this form of AssetMark.

or AssetMark to remain viable it needs to be developed as a tool seen to be of worth to Health Facilities Management not just Health Facility Engineers. Benchmarking is still a very important requirement in the industry and AssetMark can fill this requirement provided it remains abreast of the customer needs. The proposed future direction is to develop an on line version of AssetMark with its current capabilities regarding capturing of data (12 KPI’s), reporting, and user interaction. The system would also provide end users with access to live reporting features via a user friendly web interface linked through the IHEA web page.

AssetMark Development and History In 1996 The Institute of Hospital Engineering, Australia (IHEA) formed a working group of experienced hospital facility managers to investigate available benchmarking systems. Due to the lack of viable hospital facility management benchmarking processes, the IHEA applied its industry experience to develop a process that was based on best practice. A database was developed to make comparative analyses of the data and reporting. The AssetMark database facilitates the production of twelve standard reports and is capable

of producing ad hoc reports for any combination of data points.

services and processes, and create differing parameters for benchmarking.

Since 1996 sixty different hospitals have undertaken AssetMark and at least ten have been back for a second review, with one hospital undertaking the process five times. Currently the fee structure for a full completed review is $2,500. The data base for AssetMark is held in a Microsoft Access program that was put together especially for the purpose of delivering the comparison report.

AssetMark deals with these complexities by classifying hospitals by:

What is AssetMark? The IHEA’s AssetMark is effectively a structured continuous improvement program. It offers health care facilities the opportunity to identify best practice. Support from another like health care facility can also be sourced where best practice is identified outside the network. The process allows networks to: • establish performance benchmarks • monitor facility management expenditure performance • monitor facility performance • verify cost effectiveness • develop evaluation data for ACHS accreditation AssetMark recognises the differences that exist between hospitals and between similar hospitals in different states. These differences can impact on cost structures,

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

• Geographical information (6 types) • Service areas (50 types) • Hospital category (3 types) • Facility description. AssetMark can sort on these classifications and concentrate on choosing from a pool of potential benchmarking partners that are similar enough to make comparisons meaningful. The IHEA benchmarking process requires hospital engineers to identify quantitative and qualitative measures of Hospital Facility Management performance. In selecting the Key Performance Measures, the IHEA has been mindful of the considerable range of indicators that exist for Hospital Facility Management, as well as the broad range of interpretations that exist due to the number of possible variables, such as hospital management policies, facility age and condition, service levels, etc. The performance measures also cover aspects of the work that are solely dependent on maintenance management policy, strategy and tactics. The Key Performance Measures appear in the standard reports. The table below shows the Standard Reports generated by the AssetMark system. The responses in the Questionnaire that are used to

SPECIAL FEATURE generate the Standard Reports are mandatory and must be provided by the hospital engineer. If any of this mandatory data is not provided, AssetMark cannot generate the relevant Standard Report.

• the average for all records in the database;

Sources of Data for Standard Reports

The 12 Key Performance Indicators are based on the following data:

• the average of the top 5% of hospitals; • the average of the lowest 5% of hospitals.

• Hospital Facility Management cost

industry, or perhaps it may improve so much that it outstrips the performance of the industry as a whole and sets a new industry benchmark. • One hospital or network with the rest of the industry at any given point in time -–The standard reports show this relationship. • One hospital or network with any other at any time – As part of the benchmarking exercise, hospitals within networks can share information about their key performance measures. If requested, the AssetMark system can provide extra reports on areas of particular interest to both benchmarking partners.

Name of Report

Measure

Hospital Facility management (HFM)/ Total floor area

$/m2

HFM cost/Occupied bed days (OBD) or Separations

$/OBD or Separations

HFM cost/Replacement Capital Value (RCV)

• Maintenance output on preventive maintenance

Maintenance output on preventative maintenance

• Maintenance output on corrective & reactive maintenance

Maintenance output on corrective & reactive maintenance

Energy consumption/Total active floor area

GJ/m2

• Total floor area

Deferred Work/RCV

Current Trend

• Active floor area.

Active floor area/OBD or Separations

m2/OBD

Maintenance costs/Total floor area

$ / m2

Why Participate

Maintenance costs/OBD

$/OBD

Maintenance costs/RCV

Water usage index/Total floor area

KL/m2

Use of the AssetMark by hospital health facilities managers and engineers has been steadily decreasing since its introduction, with practically no activity occurring in the last 18 months. A number of reasons have been cited for the lack of activity including cost, time to do, slow process and level of information required.

Deliverables of the AssetMark System By completing the Questionnaire, the facility manager or network manager has the chance to take an objective look at the operations under their control. The Questionnaire has been designed to provide thought-provoking material that will help this process of analysis. AssetMark produces 12 reports, showing the hospital’s performance against comparable hospitals. The reports show the values for:

• Maintenance cost • Occupied bed days or Separations • Replacement capital value

• Energy consumption • Water usage

• Industry trends over time – AssetMark is able to produce information showing trends in the industry over time. • Performance state by state

• Deferred work

Participating in this benchmarking process means the facility manager seeks out best practice by measuring their own performance and aims for best practice in the improvements that are carried out. The facility manager contributes to improved health service delivery by making sure the performance of assets is in tune with hospital service delivery objectives. AssetMark can analyse the database in areas of particular interest. It can help facility managers who wish to do specific research in any aspect of hospital facility management. AssetMark allows comparison of: • One hospital or network with itself over time – By repeating the cycle of completing the questionnaire, receiving reports, benchmarking with another hospital or network and implementing improvements, a hospital can watch its own progress over time, as well as seeing where it relates to industry performance at each point. Over time, the hospital may improve against its own performance, but not keep track with general improvements in the

A market research report on AssetMark was carried out by Watts (2006) and a number of the report findings are still valid as confirmed by customer inquiries: • Limited knowledge in the industry of the product. • A need for improved performance of the AssetMark product in terms of ease to complete and information provided on completion. • Benchmarking is an ongoing accreditation requirement. • Lack of expert consultants to assist the customer in realising the full potential of the product.

Future Direction AssetMark in its current form is not being utilised by members and it is clear that a new direction is needed. The future direction is the development of an on line version of AssetMark with its current capabilities regarding capturing of data (12 KPI’s), reporting, and user interaction. The system would also

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

SPECIAL FEATURE provide end users with access to live reporting features via a user friendly web interface linked through the IHEA web page. The log-in screen would provide a secure credit card payment facility for a license/access to the KPI Benchmarking facility, proposed $750 for members. Once payment has been processed an email will be sent providing the username and password details to the client, and provide limited access to the KPI Benchmarking program. As with the current AssetMark system Health Care Facility details such as site name and user will be confidential.

Conclusion Why should the IHEA continue with AssetMark? Our charter is to serve the members and our purpose is to support members in their professional endeavours towards best practice in health engineering. To deliver effective

services to our members and educate future generations of health engineers, Institute of Hospital Engineering Australia (2008). Key performance indicators and benchmarking processes allows networks to establish performance benchmarks, monitor facility management expenditure performance, monitor facility performance, verify cost effectiveness and develop evaluation data for ACHS accreditation. The use of the current AssetMark system by hospital health facilities managers and engineers has decreased to a point of no activity occurring. A number of reasons have been cited for the lack of activity including cost, time to do, slow process and level of information required. Based on the level of activity it would not be of any value to IHEA or its members to continue with this form of AssetMark. The future direction will provide an online version of AssetMark with its current

capabilities regarding capturing of data (12 KPI’s), reporting, and user interaction. The system will also provide end users with access to live reporting features via a user friendly web interface linked through the IHEA web page. This will provide the IHEA with an opportunity to continue with the AssestMark program however it would only be of value if there is a reasonable level of participation. It now remains to determine if this future direction will be supported by the health sector.

References Wireman, Terry, (2005) Developing Performance Indicators for Managing Maintenance, Industrial Press Inc. Viljoen, John & Dann, Susan (2003) Strategic Management 4th Edition, Person Education Australia. Institute of Hospital Engineering Australia (2008), IHEA, viewed 8 April 2012, http://www.ihea.com.au/.

AssetMark Benchmarking

he Institute of Hospital Engineering, Australia’s (IHEA) AssetMark is a structured, continuous improvement program that offers health care facilities the opportunity to identify best practice. Participating in this benchmarking process means the facility manager measures their own performance and aims for best practice in the improvements that are carried out. The facility manager contributes to improved health service delivery by making sure the performance of assets is in tune with hospital service delivery objectives. The old AssetMark system involved a costly, time-consuming process that required a large amount of information to be physically recorded on a lengthy hard-copy document. The IHEA, in conjunction with Mercury Computer Systems (creator of BEIMS Facility Management software) has developed a Reports and graphs compare your results with similar health facilities around the country new online web-based system. All the original AssetMark Key Performance Indicators remain, but they can now be measured much faster with easier, straight-forward online data entry. As was the case previously, identifiers of participating hospitals remain C O N F I D E N T I A L and are not disclosed to others without consent.

The IHEA’s AssetMark program is recognised across Australia as the best Health Facilities benchmarking system. Existing benefits of AssetMark include ability to: • Monitor facility management expenditure performance • Monitor facility performance • Verify cost effectiveness • Develop evaluation data for ACHS accreditation

Additional benefits of AssetMark NOW include: • Fast, simple online data entry and email reply. • Less cost to members than the old system • Review & compare data from previous surveys • Flexible reporting

For more information and a LIVE demonstration, please visit us at:

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

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BRANCH NEWS

Vale: Chris Ford

(9th April 1943 – 16th August 2013) Long time IHEA stalwart, Chris Ford, succumbed to complications of non-Hodgkin’s lymphoma on Friday 16th August 2013. The thoughts of all us within IHEA who knew & loved & respected Chris are with Chris’ lovely wife, Ali and their extended family. Sadly, and amazingly, Ali is also battling non-Hodgkin’s lymphoma and we wish her well through her own treatment challenges.

hris will be well-known – and sadly missed – by many people across the IHEA world as he was a very major contributor to the life of IHEA since joining back in 1975. Chris knew the value of networking and continuing professional development in the hospital engineering/ facilities management field and, consequently, he was strongly committed to the objectives of IHEA in this regard. He had an illustrious history with IHEA: • 1975: Joined as a SA-based Victorian member (there was no SA branch at that time) • 1979: Instrumental in the creation of the SA branch • 1979: Became a Senior Member of IHEA • 1980: Australian delegate to attend NZ Hospital Engineers conference. • 1983 – 1986: National Vice President of IHEA • 1984: Became a Fellow of IHEA (FIHEA) • 1986 – 1989: Elected as National President of IHEA • Chris was awarded his 30 year service badge, acknowledging his dedication to IHEA. At the local Branch level, Chris performed every role imaginable - President, Vice President, and Committee Member – and, even after nearly 40 years of contributing to the organisation, he was still putting in, supporting the local branch as Treasurer. And, I don’t believe there was ever a time when Chris wasn’t a key player in organising the National Conference, every five years as SA’s time rolled around as conference convenor.

Unsurprisingly, given his experience but, more importantly, given his many fine personal attributes, Chris has many, many IHEA members that he could call friends, almost family. He and Ali regularly visited these people whilst on holidays locally, nationally and internationally. Chris’ contribution to the public health hospital engineering/facilities management field in SA shouldn’t be underestimated. He joined Flinders Medical Centre (FMC) in 1974, a major hospital in the south of Adelaide, moving from the Port Stanvac oil refinery where he spent his early years as an engineer. He was there before FMC opened, he established the building & engineering services department and no doubt helped define the services and infrastructure requirements that have served the Hospital so well in the ensuing years. He oversaw a huge range of major and minor capital works across the site over nearly 35 years and saw the hospital grow into the modern, critical health facility that it is today. Chris had a strong commitment towards the provision of safe, modern facilities that made FMC the place to be when your health is at risk – unfortunately, in recent times, both he and Ali were both forced to call on the services that FMC provides far too often. Given his dedication to IHEA, his support of his staff, his calmness and goodwill towards his peers and fellow health workers and his mentoring of fellow hospital engineers and facilities managers, Chris was widely respected and was acknowledged for his knowledge and dedication to his profession. He was a wise counsellor and sage to us all. He was the calm voice

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

Photograph taken 2011 National Conference in Adelaide

of reason – he demonstrated how to be unflappable and just “get on and do it”. As the current State President, it is my fervent hope that, in these difficult times for the hospital engineering field in South Australia, we can do justice to Chris’ efforts over nearly 40 years by ensuring that the State Branch of IHEA continues to grow and prosper – and be something that Chris would be proud of. Chris will be missed: • as a loving husband, father, brother and grandfather, • as a great hospital engineer, • as a stalwart of the southern health network’s FM effort; • as a committed servant to the public; and • as someone to whom the IHEA owes a debt of gratitude But, mostly, he will be missed within IHEA as a good friend and all-round “great bloke”. Farewell, Chris. Peter Footner State President (SA Branch) Institute of Hospital Engineering, Australia

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TECHNICAL PAPERS

H I

P S HO

f o G N I E T T R O U P T P I U S T S N I

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

BRANCH NEWS

State Branch Reports

ue to all State Branches submitting full year reports for inclusion in the 2102/13 Annual Reports, State Branch Reports have not been included in this edition of the Australian Hospital Engineer.

Annual Reports will be distributed at the Annual General Meeting (AGM) which be held at 11.40 am on Thursday 10th of October at the Sheraton on the Park, 161 Elizabeth Street, Sydney. Formal Notice of meeting will be circulated to all Members in advance of the AGM.

A E H Following the Annual General Meeting the Annual Report will be posted on the IHEA Website.

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BRANCH NEWS

National Conference

Technical Paper Presenter Abstracts The abstracts presented provide an outline of the technical papers to be delivered at the National Conference. Other presentations and activities are as contained in the Conference Program which in total provide a most interesting schedule of events of interest and enjoyment to Members.

Rob Bampton Senior Facility Planner Health Service Planning Unit ACT Government Health Directorate

Conception to Delivery the Journey of a Health Planner The fields of Hospital Engineering and Facilities Management are inexorably linked with Health Planning and it is the patient, the carer, the tax payer and the health service provider who carry the cost if this link is discounted. The path is narrow between affordability and reliability, between needs and wants, between community expectations and the tax payer’s desire/capacity to pay. Populations are growing, but of equal interest to health planners is that it is the changing population profile as we age that will arguably change future infrastructure demand. The major impact will be increased demand for health and aged care infrastructure, as consumption of health services has been and will likely continue to be much higher for older age groups. What does this all mean? Whilst it is universally acknowledged that the operating costs of a hospital consume an equivalent of the capital cost every two to three years and can continue to do so for forty years or more it is still the capital cost that captures the attention of government and the tax payer. Achieving a responsible design that results in a sustainable build meeting service requirements requires a solid link between the Health Planner, the Architect and the Hospital Engineer. It is at the project’s preliminary planning phase that the decisions are made that influence the type of build and the infrastructure included, the ongoing operational costs and the initial capital cost. This paper will focus on experiences and lessons learned in the planning journey from service identification through to the development of the models of care that inform the development of the health planning unit briefs that in turn inform the health facility planners, architects and cost planners in their development of the preliminary sketch plans and project costings.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

Narelle Turner Transfield Services, Melbourne

Developing a Facility with Maintenance in Mind When facilities are developed, the cost of on-going maintenance can sometimes be forgotten or sidelined while the stakeholders focusing primarily or solely on the design features and pure functionality. When on-going maintenance is considered during the design and specifications stage, the full lifecycle cost of both the facility and equipment can be factored into budgets. We will explore examples of equipment, building fabric, floor coverings and other elements of a property to see how planning for maintenance, at the design stage, can make an impact on the overall facility costs for the future. For instance, a specified type of HVAC system, light fitting or floor covering might be cheaper or easier to install than another, but could cost more to service and maintain in the long run. Similarly, the placement of engineering or service personnel’s accommodation will impact the time it takes to reach various parts of the hospital to undertake service and response so, thinking about this in the design and specification stage will deliver savings over the long term. The point will be made that such thinking cannot be at the expense of the hospital being functional and fit-for-purpose for clinicians and patient comfort and wellbeing. J. Bugden Managing Director – Sustainable Focus, South Australia, Australia

Lighting upgrade strategies for health facilities This paper draws on successful lighting upgrades undertaken over the last five years at numerous health facilities including the Women’s and Children’s Hospital, Hampstead Rehabilitation Centre, the Repatriation General Hospital and Coober Pedy Hospital.

BRANCH NEWS The focus is on identifying and implementing lighting upgrade measures that are cost-effective, reduce maintenance and provide improved working conditions. There is no single technology that has universal application. The measure must be matched to the space, taking into account the function of the space and the existing luminaires. Detailed information will be provided about lighting technologies used at the above sites and their performance including LED luminaires, occupancy sensors and fluorescent luminaires and retrofits in applications ranging from bed lights to toilets to medical examination rooms. Technologies that have been trialled and rejected will also be discussed. The process for implementing the energy efficiency upgrades will be discussed along with other considerations such as funding, accountability, monitoring and verification, capital upgrade and occupant benefits and facility management relationships. Marshall Glen Hall – Marshall Consulting

A Surgical Hospital Should Not be built like an Ad- Hoc Hotel What do you think the answer would be, if I asked a cross section of people in the community, whether a Hospital should be built like a Hotel or a Factory? Unfortunately, far too many would envisage Hospitals as a Hotel with accessory features, although in their mind,

it would address the Surgical & Medical needs. Unless one has a Technical background, the fact that Hospitals should be more like a Factory with Residential features is beyond their practical understanding. It is so unfortunate in Australia today; many of our Hospital Projects are now built like Hotels with the addition of Hospital infrastructure as an afterthought. At a time when we have more technology and legislation to address; we are witnessing a systematic failure towards long term flexibility and cost efficiency. As an example, Plant rooms should be given priority of location to best service the need allowing for upgrades and maintenance, so crucial for quality care. With ever changing technology and additional services, a Hospital needs to have easy accessibility to all service ducts and risers throughout the entire building. Most of the medium to large Hospitals, opened in the past five years have not prioritised this and worse; many don’t even meet the critical Building Codes! Progress can be a fragile word, particularly when we are in an economic slump and Health Care has suffered the most. Many of the Projects have now become a Design & Build contract with minimal specifications to win tender. Health Care Architects are now under greater pressure to maximise the patient room numbers and clinical flow space; everything else is sacrificed to this priority. On top of this, major building companies and industry groups are managing to open facilities that have substantial deficiencies,

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patterns of building operation, and changes in the environment which, in turn, affect the capacity or quality of healthcare service.

Irina Lindquist – Solution Architect, Schneider Electrics

Considering the current and projected cost increase for energy and knowing that healthcare facilities are among the most aggressive consumers, it is time to look into possibilities for energy savings. This can not only help in meeting the sustainability targets, including greenhouse gas and peak energy reduction but can also assist in managing an already tight operating budget by optimising consumption while retaining continuity of service. The common denominator for visualising and analysing potential solutions for better informed decision – building services information management. Analysing healthcare energy data can provide tangible benefits and enables transparency of available energy conservation measures.

Managing information from building systems for efficiency Building services in healthcare facilities are managed through electronic systems which are monitoring, controlling or simply handling alerts and notification of operating status. Whether implemented in an integrated environment or stand alone, these systems provide the healthcare facility operator with valuable insight on building performance, status of critical infrastructure and likelihood of impact on clinical service delivery. Applications and systems attached to building services accumulate significant amount of data which can be analysed and transformed into information, hence becoming an important decision support tool in managing the infrastructure and service continuity in the healthcare facility. Correlating information from multiple sources, consolidating meaningful cause – effect scenarios enables early identification of stress points, transparent and timely preventative actions. Managing information from building systems does not only apply to incidents but enable benchmarking of performance over time,

Analysing and collaboratively managing patterns of infrastructure behaviour creates visibility into potential issues and strengthen engagement with all stakeholder groups in the facility. It turns a potentially daunting experience into a positive, proactive risk mitigation approach, allowing for wide recognition, shared commitment and support in required resolution. Additionally, consolidating healthcare facility information against ACHS accreditation criteria allows an auditable path to compliance as well as a tangible proof for quality of service.

Why do so many of Australia’s and New Zealand’s leading hospitals use BEIMS to manage their facilities? BEIMS is a stable, easy-to-use system that continues to adapt to changing standards and emerging technologies at a pace that organisations can manage and afford.

BEIMS is a valuable CMMS tool to help manage your risk. BEIMS helps to ensure that regulatory, statutory, legislative, OH&S and other AS/NZS standards are met.

BEIMS is a cost-effective, comprehensive Facilities Management System that interfaces to most major financial/ERP systems, and includes an extensive asset register.

BEIMS offers first-class operational support, training and professional consulting services especially relating to

compliance and asset management.

For futher information visit www.beims.com or call +61 3 9602 2255 THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

How to design maximum efficiency into your hospital’s infrastructure Integrating all your systems delivers savings and improves care Draw on the experience of a specialist Whether you are designing a new hospital or expanding an existing one, you are under mounting pressure to do more with less – to create an environment that fosters quality care, patient safety and staff productivity while controlling costs and eliminating waste. It’s a significant challenge – and one that healthcare facilities worldwide are meeting with infrastructure solutions by Schneider Electric. Our EcoStruxure™ architecture integrates all of your hospital’s systems into a single, cohesive network. Now you can see and manage your entire infrastructure from one dashboard, maximising control and saving time. By eliminating energy waste, EcoStruxure solutions free up trapped capital, allowing you to improve margins, advance care and enhance the patient experience.

A better hospital from design to operation As part of your core design team, Schneider Electric ensures that your initial efficiency specifications never get lost in the design/build process. Our Certified Energy Architect for Healthcare keeps everyone on track to meet or exceed your efficiency targets – from the architect and technology providers, to the construction manager, integrators and installers. And because our solutions are open and scalable, they can grow as your hospital grows, maximising your investment.

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TECHNICAL PAPERS Managing healthcare facility information can also create a window into what it takes to run an efficient service, and facilitates awareness of performance beyond patients and staff through community engagement. Dean Farnsworth Group Environmental Engineer St. John of God Health Care

Lighting the Way Between 2009 to mid-2012 St John of God Health Care trialled multiple types and brands of LED lights in most of our facilities, over 100 units were installed as part of these trials across 13 hospitals in 3 states. Evidence of energy reduction from these trials was presented to the Group Management Committee (GMC) and approval was given to expand the trial to one full site. That site was Bendigo. The cost of the project at Bendigo was $285,000. The project at Bendigo started on the 18th of June and finished on the 8th of August 2012. Approximately 3,400 lamps were replaced in over 1,800 fittings. Electricity consumption data analysis showed that post project completion the electricity consumption dropped by 11.13% or 264,416 KWh per annum. Based on this reduction, CO2 emissions at St John of God Hospital Bendigo will reduce by 322.6 tonnes per annum. This is equivalent to the emissions produced by the following 130 cars (average sized, travelling 15,000 kilometres per annum) â&#x20AC;˘ 27 average sized houses â&#x20AC;˘ 6,451,761 black balloons 47,300 trees would need to be planted per year to offset the same amount of CO2 emissions. The electricity used by lighting has reduced by over 53% at the facility. This project replaced the bulk of the lighting types at the facility. Appendix A shows examples of the traditional lights, the LED equivalent and the savings found in the trials. Post Bendigo, I again went to GMC with the findings of that expanded trial and requested $1,000,000 to continue the roll out at six more sites, which was approved. To Date (8/02/13) the project has been rolled out to our facilities at Bendigo, Frankston, Pine Lodge and Warrnambool and work is currently underway at Berwick. Work will soon start at our sites at Burwood and Wendouree and will be completed by the end of the financial year 2012/13. By then we will have installed well over 10,000 units. Data analysis at each completed site continues to show good energy savings. We believe that St John of God Health Care are the first hospital organisation in Australia to take on such a bold project and think this project is a good example of planning for the future. Paul Dearlove, IBMS Pty Ltd, Perth, WA, Australia

Unlocking Information in Your Hospital Hospitals have numerous control and monitoring systems. In large hospitals this can be upwards of 50 different control systems. One of the major difficulties in managing these disparate systems is that

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

BRANCH NEWS key data is often trapped in proprietary systems.

design is ensuring that, now this data is available, it is accessible by other management systems in the facility.

Gaining access to this data is crucial to be able to manage a hospital effectively. More information on the operation of a hospital is demanded more frequently. The ability to make decisions is affected by the quality of information available to the operations and management team. As an example, a study undertaken by the European Commission – Intelligent Energy Europe program demonstrated that having automated utility monitoring systems you can assist in reducing consumption by up to 20-30%. An Integrated Extra Low Voltage System (IELVS) provides a practical solution for accessing untapped data sources using common ICT infrastructure and open standards for software. An IELVS design provides a platform to consolidate data from various systems in the hospital and present it to facilities staff in a consistent manner. Another key aspect of an IELVS

In this presentation, we will look at the IELVS solution that is being rolled out at Sir Charles Gairdner Hospital (SCGH) and how it is being used to gain access to this previously inaccessible data.

One of the information solutions built on the IELVS platform at SCGH is to take data from a range of metering sources across the site along with a number of systems in the new Central Energy Plant. Using this open data repository, the utility management software provides a range of management reports including billing, consumption league tables and sustainability performance.

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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

Platinum Partner

Gold Partners The Conference Dinner will be held on the Starship Sydney

CONFERENCE PROGRAM

CONFERENCE DINNER

This year’s Conference theme is ‘Planning for the Future’.

Keynote Speakers include: • Anders Sorman-Nilsson, Futurist and Innovation Strategist •

Kathy Meleady, A/Director, Health System Planning and Investment, NSW Health

•

David Gates, Director, Strategic Procurement and Business Development, NSW Health Department

A Full Program is now available at www.HFMC2013.org.au

CONTACT THE EVENT ORGANISERS

SPONSORSHIP AND EXHIBITION OPPORTUNITIES Sponsoring or Exhibiting will provide an excellent opportunity to promote your organisation and to maintain a high profile within the Health Industry. To download the Sponsorship or Exhibition Brochures, visit www.HFMC2013.org.au

Iceberg Events Phone: 07 3876 4988 Email: admin@icebergevents.com.au THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

IHEA Healthcare TECHNICAL PAPERS Facilities Management Conference 2013 9-12 October 2013 | Sheraton on the Park, 161 Elizabeth St, Sydney PLA

CONFERENCE PROGRAM

NG NNI

FOR

FUT E H T

URE

Day One: Wednesday, 9 October 2013 Morning

Optional Interactive Workshop

11.00am

Registration

12.00pm - 1.30pm

Welcome Lunch in Trade Area

1.30pm - 1.40pm

Conference Opening: Paul Wade, Conference MC

1.40pm - 1.50pm

IHEA President’s Welcome: Mitch Cadden

1.50pm - 2.00pm

Official Opening Address

2.00pm - 3.00pm

Keynote Address: Anders Sorman-Nilsson

3.00pm - 3.30pm

Afternoon Tea (plus Partner’s Afternoon Tea)

3.30pm - 4.00pm

ANZEX Delegate Presentation

4.00pm - 4.30pm

Conception to Delivery, The Journey of a Health Planner Rob Bampton, Senior Facility Planner, ACT Government Health Directorate

4.30pm - 4.40pm

Gold Sponsor Presentation: Armstrong World Industries

4.40pm - 4.50pm

Conference Session Conclude

4.50pm - 5.00pm

Group Photo Opportunity

5.30pm - 7.30pm

Welcome Reception / Trade Night - Sheraton on the Park

This session is proudly sponsored by

Dress: Smart Casual

Day Two: Thursday, 10 October 2013 8.00am

Registration

8.30am

Welcome and Housekeeping

8.40am - 9.40am

Keynote Address: Kathy Meleady, A/Director, Health System Planning and Investment, NSW Health

9.40am - 10.00am

Platinum Sponsor Presentation: Emerson Network Power

10.00am - 10.30am

Morning Tea

10.30am - 11.00am

Developing a Facility with Maintenance in Mind Narelle Turner, Project Director, Transfield Services

10.45am - 1.30pm

Partners Program - Sydney Opera House

11.00am - 11.20am

Lighting Upgrade Strategies for Health Facilities Jake Bugden, Managing Director, Sustainable Focus

11.20am - 11.40am

A Surgical Hospital, Should not be Built like an Ad-hoc Hotel! Marshall Glen Hall, Consultant – Healthcare Industry, Marshall Consulting

11.40am - 12.10pm

IHEA Annual General Meeting

12.10pm - 1.00pm

Lunch

1.00pm - 1.30pm

Managing Information from Building Systems for Efficiency Irina Lindquist, Solution Architect, Healthcare, Schneider Electric

1.30pm - 2.00pm

Lighting the Way Dean Farnsworth, Group Environmental Engineer, St John of God Health Care

2.00pm - 2.30pm

The Digitisation of the Built Environment - What it Means for Healthcare Facility Management Warwick Stannus, Group Engineering Manager, A.G. Coombs Group

2.30pm - 2.50pm

Unlocking Information In Your Hospital Paul Dearlove, Technical Director, IBMS Pty Ltd

2.50pm - 3.20pm

Afternoon Tea

3.20pm -4.20pm

Keynote Address: David Gates, Director, Strategic Procurement and Business Development, NSW Health Department

4.20pm - 4.30pm

Gold Sponsor Presentation

4.30pm

Conference Sessions Conclude Close

5.30pm

Bus to depart Sheraton on the Park

6.00pm - 11.30pm

Conference Dinner - Starship Sydney, departs from King Street Wharf 4

Dress: Formal

Continued over the page...

For more infoHOSPITAL visitENGINEER www.HFMC2013.org.au 22 THE AUSTRALIAN I SEPTEMBER 2013

Event hashtag: #HFMC13

IHEA Healthcare TECHNICAL PAPERS Facilities Management Conference 2013 9-12 October 2013 | Sheraton on the Park, 161 Elizabeth St, Sydney

PROGRAM (CONTINUED) Day Three: Friday, 11 October 2013 8.00am

Registration

8.30am

Welcome and Housekeeping

8.40am - 9.10am

Designing Today for Tomorrows Airborne Diseases Bill Drake, Technical Director, Sinclair Knight Merz & Annabel Frazer, Health Facility Planner, Sinclair Knight Merz

9.10am - 9.40am

Lift Based Evacuation and Hospitals of the Future Darryl Weinert, Associate Director, Fire & Risk, AECOM Australia

9.40am - 9.50am

Gold Sponsor Presentation

9.50am - 10.20am

Morning Tea

10.00am -11.30am

Partners Program - Rocks Walking Tour

10.20am - 10.50am

Campus Infrastructure Models Made Easy Elisa Knowlman, Senior Associate - Health, Peddle Thorp

10.50am - 11.20am

Planning for the Future: Meeting the Mission of Patient Care While Managing Your Energy Risk Jeffrey Staloch, Business Development Manager, EnerNOC

11.20am - 11.30am

Gold Sponsor Presentation

11.30am - 12.30pm

Lunch

12.30pm - 1.00pm

Planning for the Future Needs Robust Data Paul Cannons, Work Group Manager, Asset Management, Opus International Consultants

1.00pm - 1.30pm

Automated Guided Vehicles at Royal North Shore Hospital Oktay Gokce, Manager, Healthcare Systems, Lamson Concepts

1.30pm - 1.45pm

Conference Close and Exhibition Prize Draws

1.45pm - 3.30pm

Optional Technical Tours

6.00pm 6.30pm - 10.30pm

Bus to depart Sheraton on the Park Optional Social Dinner - Hard Rock CafĂŠ, Level 2/2-10 Darling Drive, Sydney

Dress: Smart Casual

Day Four: Saturday, 12 October 2013 9.00am - 3.00pm

Optional Social Day Activity - Fort Denison

Please note: This program is subject to change without notice. Please visit www.HFMC2013.org.au to view the most up to date program.

Platinum Partner

Conference Dinner Sponsored by

Gold Partners

CONFERENCE DINNER - STARSHIP SYDNEY

The Conference Dinner (included in the Full Registration) will be held on Thursday, 10 October on the Starship Sydney, Australia's largest and most contemporary glass cruise boat. Guests will enjoy panoramic uninterrupted views of the harbour. Set over 3 separate levels with 3m high floor to ceiling glass and an open air top deck, Starship Sydney offers guests a unique entertaining experience.

For more info visit www.HFMC2013.org.auTHE AUSTRALIAN HOSPITAL Event hashtag: #HFMC13 ENGINEER I SEPTEMBER 2013 23

TECHNICAL PAPERS

Quieting Alarms on Floor Can Pay Big Dividends

Boston Medical Centre demonstrates the value of strong alarm management Paul Barr I HH&N Senior Writer

The beeping, bleating and buzzing of the monitors in a patient room are notorious. Some of them are meant to be truly alarming and others offer a mere warning or perhaps an FYI. But knowing which is which can be daunting for caregivers and virtually impossible for worried patients and visiting friends and family members.

ven a medical device expert, James Keller Jr., vice president of health technology evaluation and safety, ECRI Institute, has been confused by hospital alarms, in his case while his mother was in critical care after a heart attack. The Joint Commission has cranked up the pressure on hospitals to do something about the many alarms that can go off in their room and produce troubled situations for caregivers, patients and patient families. The commission recently released plans to create a National Patient Safety Goal aimed at reducing the phenomenon, known as alarm fatigue, which if effective could improve care, ease the minds of patients and their families and make for a

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TECHNICAL PAPERS settings for the alarm signals and determining who has authority to change the settings. Boston Medical Center essentially has already gone through that process in a successful pilot project that now is being applied in other parts of the hospital. The medical centre yielded big dividends from its effort to make its cardiac alarms less frequent and more effective on a telemetry unit in the medical and surgical department. At a Joint Commission webinar in May, executives for Boston Medical Center detailed how it rejiggered its 16 arrhythmia alarm levels, 10 system alarms, five parameter alarm levels and its default heart rate limits. It was not an easy task from both a strategic and operational viewpoint, requiring a lot of analysis and data that weren’t easily accessed. The pilot produced a counterintuitive change in elevating the seriousness of alarms related to three heart rate measures that were the biggest source of excessive noise. Previously, at the less serious levels, generally the alarms, if ignored, would automatically reset. “We increased the acuity on arrhythmia alerts and heart rate from warning to crisis,” says James Piepenbrink, director of the department of clinical engineering at Boston Medical, in a transcript of the webinar. “We observed that while the number of alerts dropped drastically, we also had greater response to

alerts because those that sounded were all actionable, and the staff were now keenly listening for alarms. Because of the rapid decrease in noise on the unit, they could hear them and act appropriately.” The results from the pilot seem almost too good to be true. The number of audible average weekly alarms fell 89 percent to 9,967 after the pilot from pre-pilot average of 87,823. In addition to improving clinical care, nurses and patients were happier. “We went from an extremely loud beeping, noisy unit down to nothing, and to the point where it actually made us a little uneasy,” says Patricia Covelle, R.N., director of critical care nursing. “We were afraid that the monitors weren’t working,” Covelle says. The monitors were an irritant and they no longer seem that way, Covelle says. And patient satisfaction scores rose for the unit amid the quieter atmosphere. That could be good news for the patients and their caregivers across the country if other hospitals are able to mirror those results in trying to meet the new National Patient Safety Goal. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

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TECHNICAL PAPERS

Planning for Efficiency

Improving staff operations through Lean design elements Roger Call

On average, nurses travel more than five miles during one shift and much of it is inefficient motion. Regardless of caregivers’ proficiency, systemic inefficiencies such as this are a major contributor to medical errors.

any of the inefficiencies found within a health care facility can be easily remedied by adapting the same Lean methodologies implemented by manufacturers on the production line. By identifying and resolving struggles, health care providers can create spaces that support simplified work processes and ultimately shift the focus to the patients.

What is lean? Coined in the 1990s, “Lean” was used to describe the Toyota production system. The primary idea behind Lean is simply to create more value for the customer by reducing waste.

By adopting Lean thinking, organisations such as health care facilities, create processes that provide more customer value with less effort, capital or space. This streamlined approach not only lowers production costs and errors, but also positions organisations to more quickly respond to evolving customer needs. Within the manufacturing sector, there are two popular Lean approaches: Toyota production system. This management philosophy focuses on minimising the seven forms of waste — including overproduction, waiting, conveyance, process, inventory, motion and correction — to improve overall customer value. Many of these forms of wasteful manufacturing pitfalls are also

Versatile, modular furnishings within the patient room should embrace the power of space to create a welcoming environment for patients and families.

evident in the hallways of health care facilities today. For example: • Conveyance inefficiencies can be found with movement of equipment, patients or medical supplies. Moving a patient is not the same as delivering care. • Inventory inefficiencies can occur when there are either too many medical supplies on hand or when these supplies are in the wrong locations and do not get used. • Motion, a common form of health care inefficiency, occurs when caregivers have to search for medical supplies or data, or when there is unnecessary reaching, bending and twisting for supplies or patient access. • Correction inefficiencies refer to the time lost from resolving an error, such as searching for patient belongings, administering wrong or missing drugs, or reviewing supplies and data. The Toyota production system is built on two pillars: Just-in-time (JIT), a production strategy that essentially produces and conveys only what is needed when and in the amount that it is needed to meet the exact demand of the customer; and Jidoka, or “autonomation” (automation with a human touch), which allows work to be stopped in the event of a problem, such as equipment malfunctions or quality problems. With a focus on continuous improvement, JIT and Jidoka can advance an

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS resistant staphylococcus aureus (MRSA) control strategies.

Flexible work stations, such as this nurses’ station reception counter, must respond to the changing needs of facility and staff.

Through protocols such as improving access to equipment and materials staff needed for MRSA patients, creating a reliable supply of gowns, gloves and hand hygiene supplies, the team was able to free up time for staff to devote to infection control. These protocols helped the VA record an 85 percent reduction in MRSA for post-operative patients. Because of that success, the protocols were adopted within 176 VA facilities across the country. Through Lean education and a teambased effort to mitigate complexity, facilities can eliminate obstacles like the VA did to create a seamless workflow for caregivers and a better, safer experience for patients.

organisation’s overall efficiency and end-product quality to ensure a greater return on investment for its consumers. In fact, the combined power of those two pillars built on a stable foundation has helped Toyota become one of the largest automakers in the world. There have been many interpretations of the Toyota production system. However, not all are in sync with the original. Caution is suggested in evaluating consulting services. It is also important to note continuous improvement is just that: continuous. Thus, the Toyota production system is not an overnight event, but rather a prolific journey. Six Sigma. Originally conceived by Motorola in 1986 and widely adopted by General Electric in 1995, Six Sigma uses a set of quality management tools, including statistical methods and a special internal infrastructure to remove the cause of errors, minimise manufacturing variability and, ultimately, improve quality of output. Because of the need for significant mathematical analysis, Six Sigma experts or “black belts” are often required to diagnose and implement improvement efforts.

Health care applications So how do these continuous improvement approaches apply to health care? In today’s competitive landscape, cutting through the complexity of a facility with flexible solutions is just as critical to improving patient satisfaction and safety as it is to improving the bottom line. By applying a Lean state of mind from internal processes to design, health care facilities are able to identify features that add value and cost-effectively create a space that works harder for those visiting, working and healing there. Streamlining workflow. Pittsburgh Regional Health Initiative (PRHI) was one of the nation’s first regional collaboratives of medical, business and civic leaders organised to address health care safety and quality improvements. In an effort to help facilities eliminate errors, decrease inefficiencies, and deliver better patient care, PRHI looked to lean as its solution. In a joint venture with VA Pittsburgh health care System’s acute care hospital and the Centres for Disease Control and Prevention, PRHI used its methodology based on Lean concepts and the Toyota production system to improve methicillin-

Waste-free design. Often, waste is not just generated by the layout of work processes but by the layout of a hospital itself. In this instance, the best lean approach typically depends on where the hospital is in the design process. In the planning stages prior to facility construction, a 3P (production, preparation, process) approach ensures lean is the foundation for the layout overall. 3P emphasises improving processes already in place by focusing on eliminating waste through product or process design. It combines a clean slate and a diverse group of individuals to rapidly brainstorm and test creative solutions to solve the challenge at hand. The result is shifting a seemingly impossible internal challenge into a tangible, workable solution in a relatively short amount of time. Design consultants Joan Wellman & Associates Inc., Mercer Island, Wash., used 3P when planning a $300-million campus expansion within a multihospital system. Their goal was to provide flexibility for the space to fit up to 100 beds while focusing on patient satisfaction. By analysing opportunities for improvement, the team was able to find new ways to use existing, occupied space, reducing new construction by

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS over 6,000 square feet and saving the organisation $2.3 million in costs. When a facility is already established, lean design, which largely focuses on the Toyota production system’s aforementioned seven forms of waste, allows facilities to integrate flexibility where it may not have existed previously through reconfigurations, spatial considerations and furnishings. West Chester Hospital in Cincinnati had the goal of creating an exceptional health care experience for patients through Lean design. Yet, while being Lean means being flexible enough to keep pace with evolving changes, the hospital team noticed their current lab was just the opposite: casework had been built in where a modular system had been requested. With limited flexibility, the staff was unable to properly outfit two large chemistry analysers within the space — analysers that would ultimately fuel their patient-focused mission. To remedy this situation, the built-in system was replaced with modular lab furniture that allowed the room to adapt to the processes instead of the processes adapting to the room. To truly enhance the patient experience, the hospital also put focus on the patient room itself with comfortable, flexible furnishings that require minimal footprint, from modular storage systems to patient and family seating. Embracing the power of space, the hospital eliminated the industrial feel of a typical hospital by creating a warm, welcoming healing space for patients and their families while also providing caregivers with greater mobility and patient access.

Top tenets To achieve an exceptional health care experience through lean design, it is essential to follow these tenets: Continuous change. In order to keep pace with evolving patient needs, furnishings and health care design layouts should continuously be evaluated to ensure they are doing just that. Instilling adaptive flexibility throughout the design of a health care space will allow it to be changed quickly and easily should a

Lab systems should offer flexibility to meet continually changing work space needs.

layout become obsolete as the result of new technology or changing objectives.

greater quality and value for the patient to ensure better outcomes.

Surrender the space. It’s easy to design idiosyncratic alcoves and miscellaneous areas of a facility that have a single use. However, with a lean state of mind, these spaces must be reimagined to accommodate other functions when other needs arise such as respite areas or work stations, responding to the changing needs of the facility, staff and patients.

Roger Call is a registered architect and director of health care architecture and design for Herman Miller Healthcare, Zeeland, Mich. He can be reached at roger_call@hermanmiller.com.

Modular. By implementing modular furnishings and layouts, which are constructed with standardised units or dimensions that can be interchanged, health care designers ensure solutions that are reconfigurable and offer a variety of use.

‘Less is more’ Health care facility waste can hinder the experience of all stakeholders involved: patients, families and caregivers. By applying Lean at every level of care, health care spaces will be better equipped to adapt to evolving stakeholder needs, streamline processes and, ultimately, create a more comfortable healing environment overall. This “less is more” approach not only eases the emotional and physical stress often experienced by staff, but allows

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

Fresh Air

New ASHRAE reference guides hospital HVAC design Dan Koenigshofer I P.E., MSPH, HFDP, SASHE

The primary functions of a hospital HVAC system are improving indoor air quality and mitigating airborne transmission of diseases. This makes it much different from a typical building HVAC system, where comfort is the main objective.

n fact, infection control experts have provided guidelines on hospital HVAC system filtration, temperature, humidity, air change, pressurisation and exhaust, all in the name of providing superior patient care. The recently released second edition of the American Society of Heating, Refrigerating and Air-Conditioning Engineers’ (ASHRAE) HVAC Design Manual for Hospitals and Clinics incorporates this information into a convenient, detailed guide for HVAC engineers on how to design systems that meet infection control criteria, while also being reliable, low-maintenance and energy-efficient.

Major changes The second edition of the manual reflects major changes in health care engineering that have occurred since the first edition was published in 2003. One of the biggest changes was the 2008 publication of the ASHRAE Standard 170, Ventilation of Health Care Facilities. This landmark publication set the minimum standards for health care ventilation, air changes, temperature, humidity, filtration and design. When it was adopted by the Facilities Guidelines Institute (FGI) as part of the 2010 Guidelines for Design and Construction of Health Care Facilities,

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it became the minimum code adopted by more than 40 states and influenced codes throughout the world. The new manual describes how to meet Standard 170 and details how and why engineers and hospital owners may want to design systems that exceed the standard. The manual also provides background on why and how these standards evolved. Finally, it covers many topics that are not discussed in Standard 170, such as construction, sustainability, and operations and maintenance. The manual assumes that the reader has a good knowledge of mechanical engineering and HVAC design. The primary audience comprises practicing consulting engineers who are designing hospitals. However, the manual also is useful for facility engineers who wish to have a deeper understanding of how their HVAC systems work. It also may be used as a textbook for upper-division courses at colleges with health care engineering specialties.

Hospital focus • Performance Qualification of Sterilizers (assessing integrity of the processed product, as well as the performance of the machine). • Steam System Consultancy – troubleshooting, design and project management • Sterilizing Department Design – concept design, capacity studies (immediate and long term planning). • Education – conferences, workshops and seminars and on-site training

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

The HVAC manual describes the relationship between infection control and HVAC design and explains how the different components of the HVAC system can influence the transmission of airborne microorganisms. In fact, a 50-page chapter is devoted to designing various types of critical rooms and areas within hospitals, such

TECHNICAL PAPERS as operating rooms, isolation rooms, pharmacies, labs and imaging suites, and includes new data on energy use by various types of imaging systems. Another chapter is devoted to designing renovations with emphasis on system upgrades and infection control during construction. The manual explains predesign testing and facility assessments in detail with photos, and covers the ranking of priorities and budgeting for master planning. Often, phasing considerations and utility shutdowns will have a significant influence on the engineering design for the 24/7 hospital environment. It is virtually impossible to design a renovation project without consideration of the utilities that serve the project area as well as the spaces in proximity. It is common in existing hospitals that utility systems such as chilled water, hot water, emergency power and air changes are at their maximum.

Renovations that require additional utilities may require upgrading systems well beyond project boundaries. Hospitals usually are strapped for floor space, especially in mechanical rooms. Thus, it generally is difficult to replace devices such as air handling units in situ because of 24/7 operations. A new mechanical room may be required to install a new air handling unit and associated equipment. After this equipment is all online, the old equipment and mechanical room can be cleaned and repurposed. Careful phasing is required to minimise disruption to patients and hospital operations during construction. The highest probability of airborne infection comes from construction activities within existing hospitals; as a result, infection control risk assessments and interim life-safety measures receive extensive attention in a chapter on operations and maintenance, written by a hospital engineer. Unlike many facilities, hospitals have

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of their location. Numerous factors unique to hospitals drive that cooling demand. For instance, hospital buildings often have a low surface-to-volume ratio and they are less impacted by ambient weather. Moreover, hospitals contain numerous systems and devices that produce significant amounts of heat, such as imaging systems, refrigerators and intense lighting. The chapter on utilities focuses on central energy plants, which are typical of most health care facilities. The design of central chilled water plants is described in the context of the performance objectives for the HVAC system within the hospital. The pluses and minuses of various energyconservation strategies such as chilled beams, air and water economisers, and energy recovery systems are weighed.

A deeper dive The ASHRAE manual is written for experienced mechanical engineers who wish to dive deeply into health care engineering. Toward that end, a good hospital HVAC system must meet

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TECHNICAL PAPERS all performance parameters (e.g., air quality, air changes, filtration, temperature and humidity), be reliable, minimise maintenance requirements and be energy-efficient. The manual discusses the delicate balance required to meet these objectives while also meeting stringent construction budgets. Additionally, a chapter on sustainability includes a significant section on the environment of care. Generally, patients are much more sensitive than the general population in terms of the impact of temperature, humidity and air velocity. Moreover, each area of the hospital likely will see a wide variety of patient sizes, ages and acuity, requiring the HVAC system to be highly flexible. The surgery department is the economic engine for most hospitals. It is also the department that generates the largest number of complaints about temperature and humidity. Humidity is probably the number one cause of HVAC complaints in health care.

Many of these complaints, and all too often the fixes, are generated by a lack of understanding of psychrometrics. Unfortunately, the general public, operating engineers and even many consulting engineers lack the deep understanding of psychrometrics needed to design, build and operate HVAC systems that meet the demanding requirements of surgeons. The manual’s section on operating rooms also goes into considerable detail about meeting the low temperature and humidity desired by most surgeons. While ASHRAE S-170 specifies that operating room HVAC systems be designed for a temperature of 68 degrees Fahrenheit, most surgeons want the temperature considerably lower than that. Thus, it is essential to have an understanding of how hospital systems work and the impact that small changes in chilled water temperature can have on supply air temperature and humidity.

temperature, humidity and air change requirements in the surgery area, resulting in complaints by the surgery staff. Other key sections of the manual include: • A chapter on air handling and distribution systems that includes 60 pages detailing the various components of typical health care HVAC systems with control schematics and descriptions of the nuances required to provide a high-performing and efficient HVAC system. • Chapters on the business of health care, disaster planning and emergency management, and operations and maintenance provide important background for any consulting engineer wishing to have a deep understanding of all aspects of hospital operations that affect engineering systems. The better a consultant understands his or her clients’ needs, the more helpful the consultant can be. • A chapter on utilities that describes the design of boiler, chiller and emergency

Such energy conservation strategies jeopardise obtaining the exact

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TECHNICAL PAPERS power systems to serve hospitals. Many hospitals desire HVAC and electrical systems that handle a wide variety of disasters. Cafeterias may be converted to emergency holding rooms. Patients may have unknown contagious diseases. Chemical spills may require showering for scores of people. Power outages can last for days. It is the responsibility of HVAC engineers to guide owners to make cost-effective decisions that meet their unique requirements. New data are presented in the manual for energy use and heat output by various types of imaging systems. The data are based on ASHRAE’s research project on Method of Testing and Reporting of Energy Use by Medical Equipment. Through practical experience, the authors found that each of the three areas of an imaging suite — the equipment, control and patient rooms — needs its own thermostat and reheat box for individual temperature control. This is another example of a design consideration not specified in S-170 but found by the authors to be important in practice.

The design manual also is based on the highly successful ASHRAE Learning Institute classes on Healthcare Facilities: Practices for Design & Application. This course has been taught to more than 1,500 students at national and international ASHRAE meetings. Finally, many associations representing pharmacists, material processing personnel and operating room nurses, have produced guidelines for temperature, humidity and air quality in their specific departments. This manual describes how to design the HVAC system to meet these requirements. Pharmacies, in particular, require careful and unique engineering practices to meet demanding air quality and pressurisation requirements.

A broad approach The HVAC Design Manual for Hospitals and Clinics took a broad approach to providing hospital designers, consulting

engineers and facility managers with this comprehensive resource. In fact, some of the design manual authors also have been involved in revisions to the 2014 ASHRAE Handbook’s HVAC applications chapter on health care facilities. The authors also have considered other valuable documents such as the American Society for Healthcare Engineering’s commissioning guidelines and ASHRAE Standard 188, Prevention of Legionellosis Associated with Building Water Systems, as well as various other important guides from the U.S. Green Building Council, Centres for Disease Control and Prevention, and National Institutes of Health. The results of this work now are available to the entire industry. Dan Koenigshofer, P.E., MSPH, HFDP, SASHE, is vice president of health care engineering for Dewberry, Fairfax, Va. He is a member of ASHRAE Technical Committee 9.6, Health Care, and was the editor-in-chief and a significant contributor to the HVAC Design Manual for Hospitals and Clinics. He can be contacted at dkoenigshofer@dewberry.com.

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Mould Exposure & Duty of Care for Hospital Facility Managers & Engineers:

The Need for Additional Training on the Risks Associated With Exposure to Environmental Microbial Contamination Cedric Cheong I Managing Director, Mycologia & Mould Worx, MSc, B.(Env. Sci.), TAE40110

Background Facility managers of hospitals have a primary responsibility to provide a healthy and comfortable environment for both staff and patients. A primary care outcome for patients would be to send them home in a better health condition than when they arrived. However, there is recent concern in the hospital sector of the negative health outcomes from exposure to environmental microbiological contamination while both staying and working in a hospital. This concern is partly due to intensive media campaigns and several successful court outcomes that have successfully linked adverse health outcomes to exposure from mould and bacteria (e.g. Legionella). The publicity is adding unwanted stress on the already overstretched resources of the public and private hospital system. This is causing extra delays in patient admittance and management concerns and raises new legal liabilities when dealing with patients and staff being exposed to these hazards. Because there is now a link between these new hazards and poor health outcomes, it is now crucial that hospital facility managers and engineers equip

themselves with best practice training in infection control, risk minimisation techniques, and other procedures to manage these hazards on behalf of patients, staff and the general public. This editorial highlights the negative impacts from unchecked environmental mould growth in a hospital environment on the indoor air quality (IAQ), on the health of patients and staff, and on the condition of hospital equipment and assets.

Indoor air quality There is a well established body of scientific evidence showing that the air in our indoor environments, which include homes, buildings, schools, hospitals and work places, can be more seriously polluted than the outdoor air. Indoor concentrations of contaminants can be up to 10 times higher than background ambient levels (CSIRO, 2005). In addition to increased concentrations, indoor pollutants have been found to be 1000 times more likely to penetrate deeply into the human respiratory system than pollutants in the outdoor air. Indoor air quality problems arise when there is an inadequate quantity of ventilated air being provided in relation to the amount of air contaminants present

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

in that space. Structural damage, lack of maintenance, occupant behaviour and activities, and degrading infrastructure and external water ingress are common symptoms in problem hospitals. These conditions contribute to increasing risks of microbial off-gassing (odours) and other indoor air quality hazards for patients. The economic costs associated with poor IAQ are widespread and ever-increasing. In Australia, unhealthy indoor air is estimated to cost the Australian community $12 billion annually (CSIRO/FASTS, 2002). The US EPA and the National Institute for Occupational Health and Safety (NIOSH) conservatively estimated productivity losses in the region of $61 billion dollars per year due to the impact of poor IAQ. This includes the increasing costs of health care and absenteeism, reduced worker productivity, lower earnings, costs of conducting building investigations and building improvements (USEPA, 2013). Further research suggests that the building environment can affect productivity by 1.5 to 5 per-cent and cost an average of 6 minutes of productive concentration per day (United States Energy Management Institute & Hodgson M.J., 2001). The onset of sick building type syndromes (SBS), building related illness (BRI),

TECHNICAL PAPERS and in more recent times, Legionnaires disease, Severe Acute Respiratory Syndrome (SARS), avian flu, swine flu and other pandemic diseases, coupled with the ever-increasing litigious field of mould and biological contamination and remediation, has escalated these economic costs to phenomenal levels. This is due to the high expenses and costs related to the management of these illnesses, closure, renovation or remediation of buildings, temporary relocation and accommodation of individuals, insurance premiums and costs associated with medical compensation, legal action and court proceedings. In the US alone, the costs of consulting and testing services were valued at $7 billion in 2011, $7.3 billion in 2012 and projected to reach $9.2 billion in 2017. Environmental services (including mould remediation, asbestos abatement and radon mitigation), were valued at $1.9 billion in 2012 and $2.4 billion in 2017. Furthermore, the indoor air quality equipment monitoring market required to service this industry is estimated to account for $3.7 billion in 2012 and $4.7 billion in 2017.

Health effects and productivity The link between healthy indoor environment and productivity is well established. A hospital that is effectively cleaned and maintained ensures positive reactions resulting in happier and more satisfied patients, increased productivity of hospital employees, and an all-round productive and pleasant environment to recuperate and work in. In contrast, a lack of effective cleaning or maintenance can contribute to an unhealthy environment by providing sources for chemical and microbiological contaminants, ultimately resulting in negative reactions in the form of “sick” or “unhealthy” symptoms ranging from simple colds and flus to more severe conditions like nausea and vomiting. Apart from obvious outdoor chemical pollutants and indoor allergens such as cigarette smoke and animal dander, the strongest health indicator is from moisture accumulation and infiltration (dampness), resulting in microbial growth. Moisture intrusion and damp

Fig 1. Water and mould damaged medical records

conditions in buildings have been strongly associated with higher fungal exposures with established scientific publications implicating such environments with causing negative health effects and airway symptoms.

Mould The World Health Organisation (WHO) has recognised that “Persistent dampness and microbial growth on interior surfaces and in buildings structures should be avoided or minimised, as they lead to adverse health effects.” Both the living and dead forms of mould spores, and fragments of their vegetative growth, can trigger a reaction when we touch them or breathe them in. The gases they release during metabolism (mycotoxins) can also greatly affect our health. Individuals will react differently to exposure to mould related allergens, toxins and mycotoxins. Most of the time, people report musty or damp odours and do not take much more notice then that, due to the natural defences of the human body. However, for susceptible people, especially those in hospitals with impaired or immature immunological or respiratory systems, even short-term low level exposure to mould could lead to, or exacerbate, medical health conditions (Mendell et.al. 2011).

Mould can also affect us by damaging building materials, making a building unhygienic with foul odours. While odours are not in themselves toxic, they will cause adverse health symptoms in susceptible individuals. The hazards associated with exposure to mould are often dismissed as a result of a lack of awareness. This lack of education and awareness has led to many situations where individuals, staff and building occupants, are needlessly exposed to potential allergens, pathogens, toxins and mycotoxins. Unfortunately, ignorance is no defense these days and unchecked situations that lead to adverse health effects can end up in costly and timeconsuming litigation processes. In the commercial workplace environments, management increasingly needs to be seen to be working towards zero harm to all of their stakeholders and this means minimising exposure to all workplace contaminants.

Training Part of the reason why there is a lack of understanding about the potential harmful effects of mould exposure is that facility managers, cleaning and maintenance staff and consultants do not have sufficient awareness or guidance about the risks of mould exposure. This can be attributed to the lack of any formal Australian industry body offering accredited training programs on mould. Currently there are

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

Inspection of mouldy room with thermal infrared camera

a range of training providers offering training on mould remediation techniques, however, most are currently based on American systems and not well suited to Australia because of differences in legislation, building codes and metrics. As a minimum, the following summarises some key understandings that facility managers, cleaning staff and consultants should possess when dealing with the management of mould in buildings. 1. Facility managers – people who need an understanding of potential exposure pathways and health issues; with this knowledge they can then ask the right questions and communicate to stakeholders about potential hazards and mitigation. Managers need to know the limitations of their own staff and when to call in consultants as well as the benefits to them of conducting clearance testing following remediation works. 2. Cleaning staff – cleaners and maintenance staff who are likely to come into contact with mould during the course of their work need to know what to look for, how to minimise their exposure and what appropriate personal protective equipment (PPE) to use. Just as importantly, they need to know how to correctly remove the mould so that it doesn’t spread and contaminate other areas and to understand why bleaches do not work on mould.

Mould air samples

3. Consultants and Engineers – Indoor Air Quality specialists who have been brought in by managers to identify issues around a problem. Consultants and engineers need to see the bigger picture and identify potential cause-and-effect relationships. They need to know what to look for, where to look, and how to develop an appropriate sampling and analysis plan. It is essential that cleaning staff and personnel charged with the management of mould receive this level of training. The common thought about mould is it is everywhere, so why should we worry about a little bit of it on the wall or in a bathroom? The reality is that mould is a contaminant and despite the fact that it is common, it still may cause potential health effects, particularly in a hospital setting with highly immuno-compromised individuals.

Case study A major public hospital suffered mould damage when a faulty sprinkler system resulted in the medical records storage room being water damaged. Left unchecked and un-attended to, mould began to grow and cross-contaminated the entire collection of medical records. Staff accessing the records area soon complained of health symptoms ranging from headaches to several staff members reporting in sick and complaining to management. Management were

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

unprepared and this led to unions and workers compensation lawyers being involved, inflaming an already highly emotional situation. A mould management plan was implemented and resulted in the containment of the contamination, digitalisation of affected medical records and mould remediation of contaminated areas including the air conditioning system servicing the entire hospital. Communication and staff training on mould protection and continuing preventative IAQ and mould monitoring ensured that all stakeholders were kept apprised of the environmental conditions within their workplace. In another private hospital, a staff member suffered health complications following some renovation works to part of a hospital wing. Investigations conducted revealed an overall minor mould contamination throughout the hospital surfaces and in the air. However further investigation of the HVAC system, in particular the cooling coils and ducting system, revealed heavy contamination with dust, debris and mould from poor hygiene maintenance of the HVAC system. A mould management plan was recommended which targeted the hygiene maintenance of the air conditioning plant and ductwork. Water

TECHNICAL PAPERS lead to better infection control, better risk minimisation and more effective risk management methods. Hospital facility managers and engineers will be better able to confidently discharge their duty of care and calmly manage the emotive responses that can arise from these risks. They will then be able to make more informed and cost-effective decisions on behalf of the Hospitals owners and administrators.

and mould damaged material were replaced and the source of the water ingress permanently fixed. A review of the cleaning regime and protocol was conducted and targeted the areas of concern. A regular inspection schedule of the HVAC system in conjunction with regular air monitoring and clearance verification was also suggested.

Mould and Water Damage Management and Maintenance Program When a hospital is flooded or sustains water damage, one of the first things contractors tend to do is rip out and replace materials. However, this is not generally required if mitigation and structural drying is undertaken early (Category 1 water source). When water ingress is ignored or design issues are not rectified, mould can damage wall and ceiling cladding and even structural elements of the structure; all of which can be avoided with trained observation, monitoring, holistic cleaning and appropriate remediation. At the heart of any HVAC system are cooling coils (both within and external to the air conditioner). During operation, the cooling coil gets damp and organic residues can build up which decrease the efficiency of the heat transfer process and results in the use of more energy. Routine hygiene maintenance of the coils not only improves the quality of the air circulating across internal the coil, but also reduces energy use by up to 25%, particularly when bio-active enzymes are used to help reduce future growth of bio-films. Asset protection via mechanical maintenance is commonplace but Mould on air registers

Hidden mould behind wall

what is also required is a hygiene maintenance program. Appropriate inspection, cleaning and maintenance can significantly increase the service life of assets. The minimisation of corrosion on fan blades and other ducted air handler components from bio-film build up and rust can generally add five years to plant life. The AIRAH Best Practice Guideline for HVAC Hygiene describes the inspection and remediation requirements required for a clean, hygienic and functional HVAC system. For a hospital environment, the HVAC system is classified as a “Special use HVAC system”, serving buildings or enclosures that extend care to a population comprising some individuals who may have compromised immune systems or where it is desirable to control particulate exposure for other reasons (AIRAH 2010). Ultimately, scheduled hygiene maintenance not only increases the service life of assets, which goes a long way towards sustainability, but it also assists in providing patients with improved air quality. With that comes enhanced patient satisfaction resulting in increased patronage and marketability as well as fewer emergency maintenance and fit-outs, which also contributes to a more sustainable building behaviour and overall cost reduction.

For further information on training courses, scientific references and articles, remediation and sanitisation solutions and advice, visit our Indoor Air Quality Science Division at www.mycologia.com.au, our Environmental Hazard Cleaning Division at www.mouldworx.com.au or visit our Facebook page at https://www.facebook.com/ MycologiaPtyLtd.

About the Author Cedric Cheong is the Managing Director of the Mycologia Group of Companies (Mycologia, MouldWorx and HazWorx). Cedric is the co-host of the internationally acclaimed TV show, “Is Your House Killing You?” which highlights dangers within Australian homes. Cedric contributed to the development of the AIRAH HVAC Hygiene Guidelines and has written articles in AIHE and FM magazines. Cedric was an Associate Lecturer at Murdoch University and Notre Dame University teaching Environmental Science and Occupational Health and Safety. Cedric has completed training in the area of microbial sampling and HVAC investigations in Phoenix, Arizona and has visited various research centres in the Netherlands, Finland, Singapore, Canada and the USA as part of his research on indoor fungi, mould remediation, cleaning and indoor air. Cedric holds current IICRC certification for water damage restoration and applied microbial remediation and has also completed training in Friable and Non-Friable Asbestos remediation. Post remediation of air register

Conclusion The ongoing training that is required for hospital facility managers and engineers should include having a better understanding of why and how mould grows; its impact on a building’s assets; and the potential health effects for patients and staff. A more comprehensive awareness of these relationships will THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

Microbiological Contamination of Potable Water System Within Critical Care Facilities: A HOSPITAL EXPERIENCE

Dr Vyt Garnys, Travis Hale, Raghuram Muguli, Scott Stevens

he recent events nationally and internationally involving Legionella in critical care facilities highlight the damage that infective potable water quality can have on a facility, albeit in the absence of local guidelines in some states. While the immediate damage can be severe and result in the death or complications of vulnerable patients, it is also important to consider the ongoing damage that such an event can have on a hospital’s brand and reputation, particularly following widespread media exposure. CETEC have worked alongside several hospitals in identifying the issues affecting the potable water quality within the complex water distribution networks, and, using a number of different established and innovative techniques, improved the water quality significantly. The case study presented here raises significant questions to hospital engineers and facility managers of critical care facilities. Are you aware of the state of your water distribution network? Have you taken all reasonable steps to mitigate the risk of degradation in water quality, and are you aware of the real-time operation of your system? Guidelines are being revised in some states and it is possible that these will be a strengthened regulatory environment.

Water Quality Dependent on the size and function of the hospital, water is typically supplied directly from the mains or is stored within buffer/holding tanks for a period of time. Storage allows for the continual functioning of the distribution network should the external water supply be interrupted, which is particularly relevant for hospitals in Australia which have been subjected to droughts and floods. The duration that this buffer will sustain is dependent on the volume, and the capacity of the hospital. Some hospitals are unaware, however, of the quality of the water entering into the hospital Whilst it is not common for hospitals in Australia to receive processed water through internal water treatment plants (e.g. Filtration, Chlorination or Ozonation), most rely on the quality of the water to be suitable for most purposes (excluding critical, renal care or surgical wards). This reliance on the water quality within the utilities distribution network is of significant concern, as of this time, the National Water Strategy provides no quantitative guidelines

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

for acceptable concentrations of bacterial Heterotrophic Colony Count (HCC), Pseudomonas spp or Legionella within potable water. Analysis of water supplies to city hospitals found that the outlet can have microbial HCC level of 300 cfu/ml and up to 10,000 cfu/mL in country hospitals. Bacterial benchmarking is difficult due to supplier guidelines at a local level stating that ”No guideline value has been set for heterotrophic plate counts in drinking water. Marked increases in numbers after disinfection or within distribution systems should be investigated”. Whilst the quality of water may be suitable for the general healthy population, it presents clinical issues when supplied to immuno-compromised patients and visitors including those undergoing critical surgeries (e.g. heart operations), babies, children and the aged as well as those displaying some level of immunosuppression (e.g. Patients undergoing renal or Chemotherapy). It is an important fact to note, that water quality supplied by a water authority to a hospital is unlikely to be fit for all health care purposes. Whilst microbial and/or legionella concentration guidelines do not exist for potable water systems within Australia, arguably hospitals have a duty of care to provide a safe workplace for guests, visitors and staff by controlling waterborne organisms and their exposure routes. In other jurisdictions, critical facilities, such as health care, are themselves responsible for the quality of their potable and warm water systems.

Legionella Legionella bacteria including Legionella pneumophila (the cause of Legionnaires’ disease) are naturally present in the environment and can be found in all water bodies and soils. With water above 23˚c cooling towers and potable water systems (warm and cold) provide ideal conditions for Legionella bacteria to multiply to significant numbers. Since the operation of cooling towers and potable water systems generate aerosols, it is possible to distribute high levels of Legionella bacteria. People exposed to the aerosol can inhale the Legionella bacteria, which may lead to an infection known as legionellosis. Legionellosis is

TECHNICAL PAPERS a notifiable disease that must be reported to the relevant health department in all states and territories of Australia. Once affected, detailed investigations are conducted which aim to identify the source of an outbreak. Negligent building owners and operators could potentially be prosecuted.

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To reduce the incidence of legionellosis, including Legionnaires’ disease, the various states and the federal government have been developing a more comprehensive strategy since 2000. This has included a strengthened regulatory framework, increased maintenance requirements and legal responsibilities for landowners and operators of cooling tower. Currently the management of Legionella in warm water systems varies from a state to state basis. Relatively lower consideration has been given to cold water systems and/or storage systems to this point.

• Legionella risk management – water system experts

The Hospital Experience

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• Corrosion investigations • VOC emissions testing of materials and structures

Legionella was detected within their potable water network after environmental testing. At the time of detection, no state guidelines existed locally for the management of Legionella within potable water systems. After failed scalding treatments with hot water, the hospital requested CETEC’s assistance in attaining acceptable water quality within the Hospital’s potable water distribution network, with the implementation of remediation and outrage management strategies. The hospital presented a significant number of typical challenges in the management of potable water quality. Whilst initial plumbing diagrams existed, a significant number of complex modifications had been made over time. Prior to works being conducted, plumbing network dye tracer tests were carried out to determine the path and source of water within a particular building or wing and to ensure the absence of cross contamination potential. Non-return valves and rationalised water feed plumbing solutions were implemented. Following tracer testing, CETEC identified a significant number of dead-legs within the network. These dead-legs refer to points where existing pipes were once connected to an outlet; however the outlet had since been removed and the end sealed resulting in a stagnant, low flow section of the network. The presence of dead-legs create significant challenges, as these provide the optimal condition for microbiological growth due to the accumulation of dirt, organic matter, biofilms and bacteria. The minimal water flow prevents effective water treatment on the population of organisms within the dead-leg. Further to the significance of dead-legs, the infrequent use of showers and taps in vacant wards simulates the presence of dead-legs, whilst the presence of biofilms within showers heads themselves also present significant challenges regarding the management of water quality. In order to reduce the microbiological population, CETEC requested an audit and practical removal of dead legs from the

CETEC has provided services for: • Uniting Care Health • Canberra Hospital • QLD Department of Health • Liverpool Hospital • Frankston Public Hospital • New Bendigo Hospital • Royal Women’s Hospital • New Royal Children’s Hospital • Alexandra District Hospital • Sunbury Hospital • Charles Perkins Centre, University of Sydney

• Children’s Hospital Academic & Research Facility, QLD • Ramsay Healthcare - Beleura Private Hospital, St John of God Hospital, Warringal Private Hospital, Linacre Private Hospital, Donvale Rehabilitation • Eastern Wimmera HS, Charlton • Barwon Health, Geelong • Dandenong Public Hospital • Trentham Hospital

www.cetec.com.au CETEC Pty Ltd | ABN 44 006 873 687 info@cetec.com.au (03) 9544 9111 | (07) 3857 5531 | (02) 9966 9211 THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS network, decreasing the number of points of bacterial accumulation. This increased the efficacy of the cleaning methods. Following network optimization, CETEC implemented its own proven proprietary cleaning method, which essentially acted to remove any accumulation within the plumbing network that had amassed over the hospital’s approximately thirty five years of operation and to then disinfect the system, all within one hospital building shift. The novel CETEC cleaning method proved highly successful in removing a significant accumulation of organic matter, a considerable reduction in microbial levels (HCC), as well as the removal of Legionella within the plumbing system in each of the building wings. In some cases, due to the presence of residual dead-legs within certain wings, additional cleaning passes and a greater disinfection contact time were required for full removal. Following the implementation

of the CETEC method, a rapid screening technology was used to validate the efficacy of cleaning.

Innovative Technologies Rapid screening technologies were vital to the success of the remediation program. Conventional methods typically involve the collection of water samples to be submitted to a laboratory, with culturing results normally requiring between four to ten days. This has a significant effect on the logistical management of a cleaning operation. To minimize this delay, CETEC made use of the Bactiquant® water technology for the rapid screening of total bacterial loading within the potable water network. This technology allowed CETEC in under an hour to obtain results superior to plate count HCC for the network. The ability to obtain results in under an hour, as compared to the four to ten day timeframe for conventional methods

presented significant time, logistical and financial savings. CETEC consultants were able to complete the cleaning process more efficiently and verify the efficacy within a short period of time. Importantly, this method does not replace the need for verification by conventional techniques for the determination of Legionella spp within the network, but rather complements HCC measurement providing a rapid comparative and precise report for the bacterial loading within the network. A side benefit is significant savings on external laboratory costs.

Looking Forward The hospital presented a number of challenges to the management of water quality within their potable water network; however this hospital is not unique in the challenges that make the implementation and management of the CETEC cleaning regime effective.

ams Laboratories’ scientific standing and expertise make the company a most valuable resource as both an analytical laboratory and as consultants. Using internationally approved methods, standards, equipment and guidelines, ams Laboratories is NATA accredited, TGA licensed and registered with the FDA. ams Laboratories offers microbiological analysis, consultancy and training services which include:

• Air monitoring of Operating Theatre and Clean Room environments • In-house cleaning effectiveness studies (disinfectant & sanitiser qualification) • Microbiological evaluation of water systems (including Legionella testing) • Cytotoxicity studies (medical devices) • Sterility & Endotoxin (dialysis fluids) testing ams Laboratories – Sydney 8 Rachael Close, Silverwater NSW 2128 Ph: 02 9704 2300

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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

ams Laboratories – Brisbane 2/120 Bluestone Circuit, Seventeen Mile Rocks QLD 4073 Ph: 07 3295 0550

TECHNICAL PAPERS Very few hospitals exist that are not affected by sources of water with quality which may be inadequate or unfit-forpurpose when used with individuals who remain susceptible to disease as a result of immunosupression. Furthermore, the management of the potable water network quality proves even more difficult as time progresses and the number of modifications to the network increase. The presence of dead-legs, biofilm and accumulation within the network further increases the challenges presented to any hospital regarding the management of their system.

at other hospitals in Victoria has been successful for almost four years to date.

Whilst the management of a system remains complex, the hospital experience has allowed CETEC to again prove the efficacy of its innovative, rapid and novel method designed to reduce or remove the amount of bacteria within the network whilst acting to remove the accumulation of organic matter deposited in the plumbing network over many years of operation. A similar strategy implemented

Dr Vyt Garnys is Principal Consultant and Managing Director of CETEC Pty Ltd. The CETEC team of consultants has been conducting cooling tower and warm water risk assessments since 1987. This includes audits and risk management for cleanliness, water treatment, corrosion, technology assessment and chemical composition.

Critical to the success of the CETEC cleaning method is the need for rapid remediation. The implementation of innovative rapid screening technologies to compliment the currently existing conventional methods is an important tool. These innovative technologies, including Bactiquant速 water, allow CETEC to provide rapid results in under an hour, verifying the efficacy of the cleaning process and leading to the rapid remediation of the area of concern.

www.cetec.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

The Best Technology can Offer for a Hospital Hydrotherapy Pool Part 1

ALAN LEWIS I POOL CONSULTANT

This is about applying the best technology the world has to offer in water and air management for indoor Hospital Hydrotherapy Pools.

t can be said that this might be the first time in the world that this particular combination of features has been brought together in the one pool. It is exciting to know that this can be achieved in Australia – here and now – in this day and age. Further-more, the design and the implementation of these latest ideas contribute not only to better quality water and pool hall air, but also demonstrate how careful design can save running and maintenance costs for the entire life of the pool. By wisely employing the knowledge that has accumulated over the last four or five decades of swimming pool research and development, it is not necessarily beyond the reach of good, cost effective, high quality results. This has happened in a modest small Private Repatriation Hospital in Chatswood, on Sydney’s north shore, with an owner who showed the foresight, initiative and guts to reach out for the best. Hirondelle Hospital will be the first to show the world that it can be done. Indeed the Hirondelle model will pioneer and exemplify good Hydrotherapy pools of the future. It is fitting that a hospital is able to show how the best therapies are able to enjoy high quality conditions in both the water and the air for the purpose of repatriation of its patients. Some of these features are simply the result of developments and research which originated overseas while others

The Stripper left and the Drum Filter on the right.

developed here quietly over the years – and have proven highly successful because they bypass otherwise well know systems which have somehow neglected details which are important in arriving at better outcomes. These are the features which make it stand out:

BASIC DESIGN Good design of any pool must start by gathering together all the aims, values

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

and qualities that the customer wants to achieve and piecing together those alternative solutions which will provide the most cost effective result. In the end the custom design must fit the expected bather loads and be able to provide optimum conditions at all times. In some cases this might also include partial leasing the pool to outsiders under specific conditions. Chlorine is currently the most cost effective disinfectant we have and is readily

TECHNICAL PAPERS available throughout this country. Every pool design must start from the point of knowing the bather load limit that one must provide for: BATHERS + CHLORINE = INORGANIC CHLORAMINES (NH2Cl; NHCl2; NCl3) Knowing how to achieve effective disinfection (kill the bugs) with a minimum of chlorine is the real art of minimising the nasty by-products (DBPs) this chemical produces. The more we can treat the water before it actually reaches the pool itself the better; and this is why in Hirondelle, in spite of the constrictions of space in the plant room, we were able to accommodate all the features necessary for the associated equipment. These include: 1) Design of the circulation so that the injection of the treated water is close to and parallel to the floor. The aim being to sweep skin cells that fall to the floor, quickly and efficiently into the gutters. This circulation scheme is rarely designed in Australia with the result that skin cells either finish up in the sand filter or simply remain in poorly circulated areas of the pool floor. SKIN CELLS + CHLORINE = CHLOROFORM (CHCl3) Chloroform is rarely tackled directly, as it is in this pool. Research shows we should be more concerned about this chemical whether in the liquid or the gas phase. In Hirondelle thought has been given to this issue and research in Denmark (Supported by Government funding) has shown that the solution used here actually does remove the vast majority of both Chloramines and Chloroform (one of the Trihalomethanes common in pools) – particularly in the gas phase. THE GUTTERS are deep enough so that as water is pushed over the pool edge into them, the water will fall and be drained through down pipes gravitationally into a pipe which will feed that water at the desired rate into the Drum Filter and from there the filtered water will continue gravitationally into the Balance Tank. The design of the gutters

allows drawing of air across the surface of the pool through the grate into the upper part of the gutter, and from there is drawn by a fan into the upper air space of the balance tank. Thus, when both chloramines and chloroform are created in the pool hall due to splashing of swimmers, or massage jets/aerosols, or splashing through the gutter grate – they are drawn by the fan through small pipes in the uppermost region of the gutter below the grate, and finish up in the air of the balance tank. It should be remembered that in most pools these gases are usually trapped on the surface of the pool and this air is heavily contaminated with gaseous chloramines and chloroform. This is the air that competitive and pool lappers grab, as they turn their heads to breathe. This often leads to Bronchiolitis or exacerbates asthma attacks. THE BALANCE TANK acts as a large mixing tank for all the subsidiary treatment loops in this pool including the chemical treatment (pH control with CO2, Chlorine, and Ozone). The air in the balance tank is vented out to the open air in a place where there is little or no circulation of people. More of this later. Here too the air is pushed from the surface of the water to the outside but is treated at the same time to small doses of Ozone “off gas”. Normally this wasted Ozone “off gas” is sent to the open air separately – here it can help break down any chloramines or chloroform gases that might still be present in the balance tank air.

ULTRAFINE FILTRATION A lot of work and research has gone into the development of this drum filter for pools in both Sweden and Denmark. Drum filters have been used in irrigation and industrial processes for many years. Only recently Hydrotech has focussed on swimming pool applications. Together with Ole Gronborg from Denmark and other researchers they have finally arrived at a membrane on the drum of the filter with a 5 micron mesh! This means that smaller immature cysts of Cryptosporidium Oocysts might still get through the mesh with difficulty. The smaller the cysts the

more they are susceptible to high ORP (Oxygen Reduction Potential) of the ambient pool water, or heavy doses of chlorine, because their outer chlorine resistant shell is not yet fully developed. In this case we are using the former parameter (ORP) as is recognised in NSW. The most important aspect of this filtration system is that as the mesh “clogs up”, the water rises in the drum until it reaches about half the height of the drum. All this while, the drum is static. When the water reaches its maximum level limit, sensors start the motor which rotates the drum through about 400 degrees. At the same time the membrane is cleaned with fine high powered jets, which cease once the drum stops rotating. In this case it takes just 9 litres of filtered water to clean the drum and this is the amount of water that is used each time the drum automatically cleans itself. If for argument’s sake this process happens 5-6 times a day – then it would use less than 350 litres odd per week. The equivalent sand filter would need about 3000 litres once a week. Clearly this is a huge saving in water over a year. It is also important to note that in this case the skin cells shed by the bathers are filtered out of the pool in a matter of 3-5 hours depending on the bather load. The outcome is, that in this pool, far less chloroform is created in the first place. The filtered water flows gravitationally into the balance tank and from there the main circulation pump only has to draw the water from the balance tank and into the return spigots just above the floor of the pool – so as to keep the circulation flowing in a continuous circular motion – bouncing off the wall opposite and from there back along the surface of the pool into the gutter.

DISINFECTION WITH MINIMUM CHEMICAL BY-PRODUCTS The Primary Disinfection in this pool is liquid chlorine (Sodium Hypochlorite NaOHCl). The difference is the way in which it is used, and where in the

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS system,it fulfils its primary purpose of preventing cross infection between bathers and/or their carers.

In the photograph above, you will see a serpentine with about 30 metres of 1” diameter pipe. Water from the balance tank is driven through this serpentine. On the right hand section of vertical clear pipe it is possible to see bubbles of CO2 Gas as it is being injected into the beginning of the serpentine. The left hand clear pipe is the end of the serpentine, and at the bottom, can be seen a withdrawable injection spear for the injection of the liquid chlorine. There are also 1” ball valves (red handles) which can control the speed of flow of the water in the serpentine. Likewise there is a flow control for the CO2 gas attached to the lower edge of the Blue I Controller HG302 (see below).

INJECTION OF CO2 (blue hose on right) AND LIQUID CHLORINE (from below on left) INTO THE SERPENTINE

This controller has been chosen for many reasons but primarily because it has an in-line photometer which can measure colorometrically at regular intervals – day and night – the free available chlorine and the combined chlorine as well as sense the ORP and the pH electronically.

This controller has served several Olympic pools admirably and is capable of holding a pool to tight residual set points – such as needed in this case.

CO2 SERPENTINE

The point of this CO2 Serpentine is that (i) It is always possible to adjust the flow to ensure that every last bubble of CO2 is dissolved before it leaves the serpentine. Thus none is wasted. (ii) By the time the water reaches the end of the serpentine the pH in the

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TECHNICAL PAPERS standard. The reason for this higher standard is to enable prompt responses to critical events which might lead to extended closure of the pool. Hospital, School, and Learn to Swim school pools, have to be able to cope with faecal accidents from time to time – which normally require lengthy closures, if the turn-over is slow. A dye test run during the commissioning of the pool showed that chemical injected into this pool – is fully dispersed to all corners of the pool within 2.5 minutes! This means of course that the pool can quickly be brought back to a healthy safe condition within an hour.

CONSERVATION OF ENERGY; WATER; CHEMICALS;& MAINTENANCE The Blue I Controller

water has been reduced to about 6.3 – 6.4. At this level of pH - 96% of the Sodium Hypochlorite is converted to Hypochlorous Acid (HOCl) which is the free available (active) chlorine that does the disinfection work. If the pH in the pool is 7.2- 7.3 only 66% of the Chlorine (were it injected directly into to the pool) is converted to HOCl. (iii) So now, all of the water that leaves the serpentine is being “superchlorinated” as it moves on to the next stage of its return to the balance tank. It is important to note here that most installations simply inject the CO2 into the return to pool line without bothering to ensure the dissolution of the gas. This results in a huge waste because CO2 does not dissolve readily in hot water (34 degC ). When injected in this way about ¾ of the gas is simply wasted as it passes through the return-to-pool pipe directly into pool (usually injected about 600mm below the surface or alternatively in the centre line of the pool floor) – From there it quickly rises in bubbles into the air above the pool surface and joins the Chloramines and chloroform gases sitting on that surface. Carbon Dioxide gas too is heavier that air.

THE SECONDARY DISINFECTANT IS OZONE (03)

The super-chlorinated water in the CO2 serpentine – is now directed to the Ozone system just after the injected Ozone passes through the two Venturis that suck the manufactured Ozone into the four mixing vessels. The concentrated chlorinated water from the serpentine now mixes with the Ozone as they pass together into the mixing vessels themselves so that by the time that mixture leaves the mixing vessels on their return to the balance tank that water is highly laden with short lived Hydroxyl Radicals which are the strongest disinfectants we have available. All of the treated water is now capable of inactivating even the hardiest of Cryptosporidium Oocysts that might appear in this pool. Fortunately in Australia our pools have rare reported outbreaks of Cryptosporidiosis about once or twice every three years and these are usually quickly brought under control by the health authorities. The USA on average has 25 outbreaks every year – which lead to major close downs of pools experiencing such an event. THE FAST TURN-OVER of 55 minutes for this pool (volume: 45,000 litres) is above

In relation to “conventional pools” with Sand filters, it has been clearly shown that there are very significant savings in energy . Where this pool is able to fine tune the turnover rate during the daytime with a 1.1 kW- efficiently run- pump; the equivalent pump for the same sized pool would require at least a 2.5 kW pump – which amounts to a saving of 56% of the energy expended on circulation. On top of that we will be able to run this pool at night time with even less energy, by extending the speed of turnover by 30% approximately. The cost of running pool circulation pumps is the most costly part of public pool maintenance, so one like this that relies on gravitational flow and filtration – rather than having to push the water through a deep sand bed to achieve the same quality water – pays for itself very quickly. My calculations lead to possible savings of over $5000 in one year – as against the equivalent sand filter. The conservation of water that the Drum filter brings is massive – more the 66% of waste water is saved against that required by a sand filter. In this case, about 150,000 litres per year, or roughly three times the volume of this pool / year. With this saving of water comes of course comes additional saving in chemicals. On top of this the weekly backwash of an equivalent sand filter often takes more than half an hour every week.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS The CO2 Serpentine reduces CO2 wastage to zero and reduces chlorine demand by roughly 30% so that when the pool is run at ORP of 780 mV and pH 7.1 – 7.3 – the free chlorine residual will be around 0.8 mg/l – without sacrificing the “kill power” of the water. Since no dissolved (free) Ozone is allowed in the pool (NSW regs) while bathers are present, the Ozone dosage is raised at night and weekends when the pool is closed with the aim of breaking down any remaining chloramines. The final piece in this configuration is another imported development from Denmark – namely the CHLORAMINE/THM STRIPPER. Here water from the balance tank is allowed to drip down like a small fountain inside the vessel – as air is drawn up through the droplets showering downwards. This converts the chloramines and the chloroform from liquid to gas which then is also blown into the balance tank and from there into the outside air. This process removes more than 85% of the unwanted liquid chloramines and chloroform from the water that passes through it. A small 1/3 kW pump works day and night at slowly and steadily removing these nasties from the system before they get to the gas phase in the pool hall.

THE CHLORAMINE/CHLOROFORM STRIPPER

GOOD MANAGEMENT OF POOL HALL AIR It is only in the last year or two that advanced competitive pools around the world have begun retrofitting the management of the pool hall air at levels where it will do some good. Prior to that all pool hall circulation in Australian pools happened above the heads of the deck hands and life guards – and many had to find alternative work as they suffered severe Bronchiolitis from the constant breathing of Chloramines and Chloroform gases present in the lower parts of the pool hall space. This might be only the second pool in Australia (after the Ian Thorpe Aquatic Centre) that has been purpose designed to remove the unwanted DBP gases from the pool hall. Readers are invited to contribute their own opinions on the content of this article or seek further elaborations and clarifications of anything they have found difficult to comprehend. Part two will deal in further detail with the pool water chemistry involved here; and attempt to show how important Ozone is in breaking down unwanted DBPs which have not been discussed as yet, and demand much more attention than has been given in the past. You can reach the author by emailing Alan on aquazure34@gmail.com

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TECHNICAL PAPERS

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TECHNICAL PAPERS

Innovation in Health Design: The Royal Victorian Eye and Ear Hospital

Alex Holderness I Health Facilities Design and Development

Over the course of the year, I’ve been speaking to some of the biggest influencers in health facilities design across Australia to gain an insight on some of the biggest projects impacting the industry.

ith the era of new technology rapidly evolving, there’s no doubt it’s an exciting time for healthcare, where innovations can quite literally, change lives. One project, capitalising on these new opportunities is The Royal Victorian Eye and Ear Hospital (RVEEH). I recently sought the exclusive insight on the project from two people instrumental in the project, Jenni Gratton-Vaughan, Executive Director Strategy, Planning and Redevelopment at RVEEH and Neil Appleton, Design Director at Lyons Architects. Jenni and her team manage the interface between the whole design process and the construction of the work with the on-going operations of the hospital. She works closely with the Project Director from the Victorian Department of Health, through which the Project is funded with funding also contributed from the hospital. Neil is a design Director at Lyons and leads a large team on the project, working closely with Jenni, liaising with the users and the Executive Strategic Group to design the facility. The hospital itself has been planning to redevelop since 2001, Lyons Architects came on seven years ago to undertake a detailed Feasibility Study. Following approval to proceed from the State Government in 2012, the hospital design team started to work on two major arms of the project:

The enabling works package, which is a reasonably large project in and of itself, consisting of a major reshuffle of areas within the hospital, to allow the team to then build the main part of the redevelopment. The team is currently in the schematic design phase for what’s being called ‘the main works’ which is basically building the central core of the hospital to join the two existing towers and also the full refurbishment of the hospital beyond that. Neil and Jenni talked me through the stages of the project:

• Initial stages When the planning first began there was some discussion around whether the hospital should move out to a Greenfield site, or stay put. It was determined that the hospital would be better for our patients staying where it was. Its location in Melbourne is fairly central to Victoria for patients and our workforce. If we had moved, that would have created a lot of connection problems; we’re very much a hospital that runs on visiting medical officers rather than a lot of full time medical staff. The decision was to keep it where it was and then ask the question - How do we design the renovated hospital to be better for the ‘senses’?

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

• Adapting to a change in flow The existing hospital has two main towers which are only connected on the very lowest levels. It was originally built as a 250 bed hospital. Over the years the model of care has changed, particularly around ophthalmology services, which means a lot of surgery now can be done as day cases and this change to our model of care doesn’t require as many beds. The knock on effect of that is that the existing layout has become poor. Areas that were once wards have now been taken over to run clinics, or to be office areas – fixing this improper use of space issue has been driving some of the design. The remodelled hospital will all flow seamlessly and have a much better design fit for our current model of care. For instance, at the moment the clinics are spread vertically through the towers requiring patients to move up and down to visit different clinical departments. The key aim for us was to bring all of the clinics closer to the ground floor and unite them on one level. You can imagine from a patient’s perspective, particularly one with a vision or hearing impairment where disorientation is a concern, the idea of making it immediately accessible from the ground floor, is really a fundamental improvement. Additionally, the consolidation of clinics onto one level is going to improve the way the hospital functions on the refurbished upper levels because the lifts won’t be tied up moving

TECHNICAL PAPERS patients as they can very simply move between the first and the ground floor. Similarly, our theatres and recovery areas will be integrated on one floor, rather than across three levels. This will be much better for our patients and much more efficient for our staff.

• Designing for the ‘senses’

wary of shadowing and perceptions of tripping to ensure people don’t have issues with their impaired perception. Demographics – What we’re tending to find is a lot of our patients who are elderly have comorbidity issues that need to be catered for. That’s a common theme across all health agencies. All hospitals these days to deal with an aging cohort with comorbidity concerns on top of hearing and vision issues.

There are many children in the hospital, particularly in the cochlear implant clinics. We are thinking about how we’re going to cater for the younger people within the facility, to make sure that they feel included. Finally, the hospital has a particular connection into some of the indigenous community as well; we need to also make sure that we’re accommodating their needs within the facility so they feel comfortable and safe.

Along with uniting the ambulatory care on one level, and other collocations what we’ve tried to do is design the hospital so patients and visitors can find their way more intuitively, rather than locating things in a counter-intuitive way. Secondarily, we’ve even been looking in a significant amount of detail at the patient cohorts, the vision impaired and the hearing impaired. We have been meeting with patients, hospital and sector specialists who work with these people all the time, to really understand what some of the common issues are. Out of this research we’re starting to learn a lot of things about particular concerns that they have in terms of finding their way around and feeling empowered, not anxious. Part of what we’re trying to do in the redevelopment is to reduce the anxiety of patients within the facility so that their experience is far more pleasant and acceptable. Hearing impairment – we’re finding there are a significant amount of balance issues for this cohort. We need to be designing and catering for these people who have balance concerns, through the facility. A lot of this has to do with making sure that there aren’t fall-offs and tripping hazards and that our clinical rooms are designed to cater for their abilities, for them to lie down etc. There are particular issues around how you create enough space in clinic rooms to manage with patients, carers, interpreters and clinicians in one area at the same time. Vision impairments - Obvious things such as seriously high visual contrast to delineate between floor surfaces and wall surfaces and, where handrails are running along walls, need consideration. They have to be clearly defined so that they’re not blending into the walls. Things have to be very apparent, and we are THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS • Designing with an evidence based approach We’ve all been doing lots of desktop studies on different clinics and hospitals around the world, particularly for eye and ear diseases, that have tried to deal with these issues, to learn from their successes and mistakes. We’ve had some interesting ‘show and tell’ sessions from leaders at the Eye and Ear Hospital who have done research tours around the world to better understand how to approach the redevelopment. This ensures our design is based on best practice, particularly as found in America, Europe and Asia. We’re seeing real evidence of what is being done in terms of both successful innovations and, occasionally, poor outcomes from redevelopments. The Royal Victorian Eye and Ear Hospital is a specialist hospital, with an international focus, not just a local state focus, so it’s really important that the hospital can attract higher technological interest from research and industry groups. For example, we’re involved in the development of a bionic eye as the clinical partner in the Bionic Vision Australia Consortium. The hospital needs to be able to attract the best from around the world to come and work here by providing great high tech research space etc.

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We want to enhance a very close relationship we already have between clinical work, research and teaching. The Centre for Eye Research Australia and University of Melbourne Departments of Otolaryngology and Ophthalmology are collocated on the RVEEH site which enables research outcomes to translate into clinical practice very quickly. This can often be seen as three separate things but we’re trying to make it an incredibly apparent and evident connection by increasing the level of visibility, transparency and connectivity. Another important thing that we’re throwing into the mix is a way of making the facility an educational site for the community so that at every opportunity we can make learnings apparent. This engenders a significant amount of interest and confidence in the work that’s happening in the hospital and improves the sense of outreach into the community. People get to see the value and importance of what’s being done. For example, the bionic eye and cochlear implants. They’re incredible ideas and amazing innovations in medical science that will benefit the world in many ways. To get a greater level of understanding in the community it’s important to build a greater volunteer base to interact with patients and visitors. We’re finding within the hearing and vision sectors, there’s no substitute for human connection. One of the things that people with either of the sensory impairments tell us is that they can feel incredibly isolated and be quite anxious. The hospital has been running a volunteer concierge service mainly on our ground floor in the front reception area, but the hospital is really looking at expanding this idea as part of our approach going forward. Our design needs to incorporate an increasing concierge capacity across the hospital.

• Overcoming the biggest challenges A big challenge in the long term redevelopment is construction fatigue and decanting staff through the stages. The construction phases will take five years and there’ll be a lot of people working around that. It’s key to have open and transparent channels of communication back to the project team to make sure that any concerns people have in their operation of the hospital through the construction phase are met through negotiation with the builder. Even throughout the design phases the challenge is for deep and open consultation with a broad range of people to make sure we get the staff’s requirements and the hospital vision captured adequately. Our other key challenge is that we will spend years doing a whole lot of really terrific work on designing these areas, but our service delivery may not change with it. To avoid this, we’re also running our own change map alongside every department, clinical or non-clinical so they have a template that demonstrates what their current practice is and what their future practice needs to be to maximise the new design.

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We’ll be spending a great deal of time helping them move towards a new way of working, and some of those things they can implement, now or in the next year or so; some things they will be able to finally implement in the redeveloped hospital.

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

Cogeneration & Trigeneration

itâ&#x20AC;&#x2122;s not all about Carbon Craig Walter I Manager â&#x20AC;&#x201C; Emerging Markets, A.G. Coombs Pty. Ltd.

Retrofitting buildings with cogeneration and trigeneration can be a positive investment decision, reducing energy costs, improving NABERS ratings, providing energy security and improving overall system reliability. The application of the technology has specific design characteristics, which must be fully understood and correctly implemented to ensure that planned and optimal return on investments are achieved. What is cogeneration and trigeneration? Cogeneration technology involves an efficient application of gas powered electrical generation, where heat recovery, as a by-product of the gas generator, is used for building heating.

Trigeneration is where an additional application of the heat recovery is used for cooling, via an absorption chiller, providing a third form of output energy. For some time, building owners have been demonstrating the use alternate energy sources, such as replacing

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

electric duct heaters with gas powered heating hot water systems, which use a cleaner and cheaper fuel source (natural gas) to provide the same function. With further increasing energy prices and the rapid demand for greener buildings, cogeneration and trigeneration should form

TECHNICAL PAPERS a key component of any underperforming building energy assessment. Retrofitting buildings with cogeneration and trigeneration may be the initiative required to secure a building energy rating not possible through energy reduction initiatives, due to limiting building characteristics that would be expensive or impractical to change. The ability to implement a large energy initiative within a building, with limited interruptions to tenants, can be a very attractive option for many building owners.

Why is energy modelling so important? Building services are typically designed to cater for peak conditions, ensuring that thermal comfort can be maintained at all times. Under these selection decisions the focus is primarily on the occupant, ensuring that their operations are not affected. The selection of cogeneration or trigeneration systems often requires a different mindset, which is often misunderstood, due to different drivers. Key considerations when modelling cogeneration and trigeneration systems include: 1. R eturn on investment â&#x20AC;&#x201C; this is the most common key driver of choice, requiring a change of focus from an engineering biased selection process to a finance driven selection and justification. The sizing and selection of a system is therefore driven through detailed energy and financial modelling targeting optimal return, usually measure by the assessment of Net Present Value (NPV) over the life of the system. 2. S upplementary system â&#x20AC;&#x201C; cogeneration and trigeneration systems are typically designed to supplement existing services, and therefore do not require peak operating capacities. The sizing of the system is therefore based on optimal overall efficiency and financial performance. 3. M aximising performance through Successful Integration â&#x20AC;&#x201C; the operating ranges of cogeneration systems can be narrower than existing services, depending on the technology choice.

To achieve optimal performance of a cogeneration or trigeneration system, full load or near full load operation is usually the best solution. If there is a level of unease with the overall outcome, it is better to undersize rather than oversize.

Should I consider cogeneration before an energy reduction project? Following the implementation of cogeneration within a building the equivalent cost of electricity for your building will reduce, potentially making previously considered energy initiatives less attractive. In finding the best solution, peak electricity, off-peak electricity and cogeneration electricity costs must all be considered, and the ability to accurately model the time of day for the energy reduction initiative and appropriate energy rate (often a combined rate) becomes more complex. Considering energy reduction initiatives in parallel with cogeneration is the preferred method to ensure that all initiatives are

appropriately assessed and that the building is not left with underperforming energy consuming assets. A detailed energy modelling plan will consider all energy reduction and fuel substitution initiatives in unison, with the further development of an implementation plan that will deliver maximum return on investment.

Building considerations Remembering that cogeneration and trigeneration systems are typically driven by maximum return on investment, the method in which the systems are integrated within the broader building system should be conducted in a manner of maximising the performance of the cogeneration or trigeneration system. The integration of the electrical and mechanical services should be designed and setup to achieve maximum use of the electrical supply and heat recovery of the gas generator. This may require existing services to be modified to maximise use of the cogeneration and trigeneration system.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TECHNICAL PAPERS

Network connection If the system is designed to operate in synchronisation with the grid (most often the case) then during the early design stages the impact on the external electrical supply network must be reviewed in conjunction with the electrical distributors. A common concern is the potential impact of external faults on the distribution network, for example, a power pole short circuit. In these circumstances, the gas generator will supply current to the electrical fault for a very short period of time, in addition to the main grid supply. This situation is reviewed as the “fault level”, and is measured by the short time period of current that can be supplied. For example, a 1MW gas generator may supply around 8,000 amps for a short period of time to the fault. Depending on the head room in the local electrical network for the additional fault level, the electrical distributor may require

fault limiting devices to be installed, or may decline the application to connect to their network. Early engagement with the electrical distributors is essential to lower the risk of future challenges.

Key project delivery factors The complexities around cogeneration and trigeneration systems have driven alternate delivery models, often based on end-toend delivery and warranted performance outcomes. When selecting the appropriate delivery model to match both risk appetite and cost effectiveness several key factors should also be considered: • Ability to accurately model both the technical and financial aspects of the projects • Extensive assessment of technology options • Experience in grid connection agreements • Quality of gas supply

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• Exhaust filtration requirements • Location and noise emissions • Ability to conduct works within occupied buildings • Surety on ongoing operating and maintenance costs • Experience in successful integration of cogeneration and trigeneration systems • Ongoing support and performance tuning Cogeneration and trigeneration systems can be an attractive solution to lower energy costs and carbon emissions. The ability to select the optimal solution for each facility involves an extensive design and liaison with key stakeholders to ensure future risks are mitigated and optimal return on investments are met. Article first published in Retrofit Australia magazine, Volume 1 Number 2 2012; www.retrofitmagazine.com.au

*Illustration purposes only E&OE THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST

New Report Provides Valuable Communication Tool Todd Wilkening, CHST

ealth care executives are evaluated on growing the business through value elements worthy of investment and facilities managers need to think of their departments in the same way. In the past, the tools to make such evaluations have been rare. However, North America’s three leading health care facilities and engineering societies have been working to change that with the release of the Health Care Facility Management Report, a benchmarking project currently in its 2.0 edition. The report provides facilities managers with the ability to show the value of their departments and their influences on improving cash flow and business outcomes so they no longer are perceived as simply an expense.

Moving beyond expenses Developed by the Health Care Institute, an alliance partner of the International Facility Management Association (IFMA), in cooperation with the American Society for Healthcare Engineering (ASHE) and the Canadian Healthcare Engineering Society (CHES), the report provides operations and maintenance data for acute care hospitals, medical centres, critical access hospitals and rehabilitation centres. Units of measurement within the primary categories of real estate and property management, risk management, facilities, construction, utilities, engineering, maintenance, environmental services and linen are captured and broken out. Users can query on hundreds of benchmarks for the areas based upon organisational demographics such as type, size, region and scope of service, among other variables. But the Benchmarking 2.0 Health Care Facility Management Report goes further by using the commonly accepted health care financial matrix of “adjusted patient discharges” to help health facilities managers to move beyond an expense mindset and make a positive financial case to senior-level executives. This sets the stage for facilities managers to easily begin rolling out cumulative cash flow, return on investment and time value of money metrics. This methodology also has caught the attention of other international facility management organisations such as the European Facility Management Network and the Institute of

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

Hospital Engineering, Australia. United States-based Practice Greenhealth also is endorsing the report.

Putting it together The Benchmarking 2.0 Health Care Facility Management Report survey was developed last summer through IFMA’s online survey management system entitled Benchmarks Exchange (BEX). Based on the Benchmarking 1.0 survey questionnaire, which was conducted in 2010, modifications were made and new questions were added related to risk management, property, real estate and construction management. Questions were asked in an objective fashion in order to obtain responses that were truly representative of industry practices, and committee members examined each question to make sure they were all clear, unambiguous, concise and relevant. In July 2011, IFMA, ASHE and CHES members received an email directing them to a link to the online survey. Respondents were asked to provide information on the facilities they manage for a 12-month period. The majority chose to report the data for calendar year 2011. A total of 262 hospitals participated in the survey during a five-month period. A survey completion rate of 80 percent or above was considered usable, yielding 184 surveys for analysis. To ensure high-quality data, highly structured coding and data verification procedures were used. In addition, all variables and values were checked to verify that they were within appropriate ranges, and inappropriate outliers were corrected or removed. A full statistical analysis followed, using a professional software package. Standardised data analysis procedures included reviewing descriptive frequency counts and cross tabulations of responses for variables of interest. To maintain the real-world usability of these findings, statistics most often are provided in terms of absolute number of responses, percentages and mean averages. Percentages may not total 100 percent due to rounding or the acceptance of multiple responses. In many cases, some respondents did not answer all questions, so the base numbers differ among the findings. Additional calculations were made to determine cost and utility consumption per square foot, square footage per fulltime equivalent employee (FTE) and cost per discharge. Utility

TOPICS OF INTEREST consumption data were changed to match the unit specified. Canadian cost data were converted to U.S. currency and metric numbers were converted to standard.

electricity in a home based upon the average number of kWh used per day (30.16 kWh) as provided by the U.S. Energy Information Association.

Handy toolbox

Declining hospital use and length of stay have been attributed to cost-containment measures instituted by the Medicare and Medicaid programs. This places more emphasis on the need to maximise cash flow when patients are visiting the hospital. The average total utility cost shows a mean of $230.49 per patient discharge. As with cost per square foot, this is 71 percent of the total utilities.

The Benchmarking 2.0 report can be viewed as a handy toolbox to help facilities managers show the results that are important to senior-level executives. Data are at their fingertips to learn the true cost based on square feet and adjusted patient discharge. When it comes to overall utility consumption per gross square foot (GSF), for instance, electricity sharply remains a key contributor. The high consumption multiplied by the high cost will help facilities managers as they try to encourage their senior executives to invest in energy conservation strategies. Based upon the survey results for cost per GSF, the mean for the total cost of utilities is $3.23 per GSF, with electricity accounting for 71 percent. With natural gas accounting only for 25 percent of the total cost of utilities, it is no wonder emphasis on reducing electrical use takes centre stage. Consumption per patient discharge is startling compared with what is consumed in residential settings. The average number of kilowatt hours (kWh) per patient discharge is 1,829.04. Thus, each patient discharge is equal to more than two months of

This makes the case that when business volumes are down, energy conservation becomes increasingly important. Here is where the facilities manager can really improve the bottom line and be able to prove it to the CEO. For example, a facilities manager can sell an energy costcontainment strategy to the C-suite as the path to improving cash flow. The facilities manager can state that the facilities department desires to reduce utility costs by 10 percent or 32 cents per square foot. But, a better way to frame it is, â&#x20AC;&#x153;We will improve our organisations finances through reducing utility consumption by 10 percent in order to improve cash flow by $23.05 for each patient served.â&#x20AC;? With regard to total maintenance expenses, the average mean was $5.04 per gross square foot with 45 percent being

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TOPICS OF INTEREST spent on interior systems. As hospitals continue to retain their competitive advantage through more elaborate patient care environments, it will be interesting to see if the number of dollars spent on interior systems grows. On a cost per patient discharge, only an average of 35 percent is being spent on interior systems. Benchmarking 2.0 also provides even more detail about where hospitals are spending their dollars and identifies what maintenance positions are the most important to invest in today. This is where health facilities managers close the communication gap with senior executives as the adjusted patient discharge is one of their key financial indicators. Business analytics is the buzz phrase in health care today and the savvy facilities manager must embrace and master it from the top down.

Targeting the Triple Aim The result of this improved financial acumen ultimately will help the facilities manager play an active role in the movement toward accountable care organisations (ACOs) or ACO-like enterprises. The Accountable Care Act has developed the Triple Aim approach to ACOs that call for them to improve the health of the population served, improve the experience of each individual

patient and improve affordability as measured by the total cost of care. Facilities managers hold in their hands many influences that are targeted by the Triple Aim. These include aesthetically pleasing environments, reliability, sustainable practices and maximising the life cycle of buildings and equipment, to name a few. Not scoring well with the Triple Aim can mean lower governmental reimbursement and a black eye in the community. Health care organisations must provide measurable data to maximise reimbursement. Facilities managers need to demonstrate how they measure up. This is the key advantage of the benchmarking report, which allows health facilities managers to drill down into literally hundreds of benchmarks. In general, health facilities managers will have access to key benchmarking matrices to compare similar organisations in terms of square footage and patient volumes, including usage and costs, and best practices used by others. This data can be used to lower operating expenses and offer the ability to provide high-quality, measurable outcomes and deliver reports tailored to senior executives and facilities managers simultaneously. Benchmarking leads to questions of confirmation and opportunity to further the business of health care. Through the Benchmarking 2.0 report, a facilities manager can increase his or her net worth as a business partner in common terms that senior executives and the facilities manager will understand.

Communicating effectively Senior executives donâ&#x20AC;&#x2122;t have time to master the same level of operational knowledge as do facilities managers. They are preoccupied with budgetary pressures and analysing competitive forces. What executives in the C-suite need to hear is that the money they spend will come back as increased revenue and profits in support of the triple bottom line. To communicate effectively, health facilities managers must speak differently to senior executives than they normally do. They must make it easy for executives to understand their needs in a language they use every day. Todd Wilkening, CHST, is director of facilities at Ridgeview Medical Centre in Waconia, Minn., and also serves as chairman of the International Facilities Management Association Health Care Instituteâ&#x20AC;&#x2122;s Benchmarking 2.0 Committee. He can be contacted at todd.wilkening@ridgeviewmedical.org. This article first appeared in the June 2013 issue of HFM magazine.

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It’s Time to Think Outside the Box for Funding Alex Holderness I Health Facilities Design and Development

Monash Health are currently in the process of building new and improved facilities at Dandenong Hospital to ensure continued access to the highest quality of care for the community.

he work will redevelop a number of community and ambulatory care services which are provided in disparate locations and to bring them into one central precinct in central Dandenong. As with many other projects one of the key challenges has been funding. With funding increasingly becoming a barrier to development, I wanted to speak with the Capital Planning Manager at Monash Health, Anna Morgan to get an insight on the innovative approaches used to get funding. Five years ago Monash worked with the Department of Health to develop business cases for funding. However, they were unsuccessful in bids for funding from State and Federal Government. The conditions of the buildings housing the health services that were being provided were becoming critical, another set of business cases and another source of funding solution had to be found. The solution came from internal funding; Monash acquired long term leasehold of a property and then arranged for the landlord to fit out the building in accordance with their design, over the ten year lease period, Monash will pay back the landlord for those fit out works. The project is currently well into design, closing off schematic design and into design and documentation with the aim of going out to tender by the end of July, and engaging a key contractor in August.

Anna explained how there’s a need for a new form of thinking in Victoria: “We are having to get a bit smarter with our funding and make it stretch a lot further, we’re not getting the same sort of funding. We need to think outside the box if we want to keep resourcing our facilities, so not just looking to government for funding. Look to inside your organisation, sponsorship and other support methods, it’s a key way to get funding to renew services and renew facilities. There are some health services in Victoria that are starting to do that, but many that still aren’t looking beyond the main stream.” We also have to be a lot smarter in the way we’re using the budgets, it’s coming through to a much smaller level. In the past we might have got two or three million for a project, now we’re expected to achieve a small refurbishment with a million dollars instead. It’s a huge challenge to prioritise the key aspects of a development rather than doing the full project”. Anna shared with us some of her key lessons learnt from the various stages of funding:

Building the business case • Know the figures inside out – it’s one of the fundamental parts of a business case you have to be clear and transparent with your figures throughout to fully document the funding, it’s absolutely critical.

• Key things that made or business case successful was that we were able to find some efficiencies and savings in co-locating a whole lot of services that were in different locations. Have a look at the layout of your services; are there quick wins to be made with existing property? • Our business case could have been stronger in terms of clarity around the finances. Don’t underestimate how much this helps the organisation understand and accept the project. With innovative funding methods, it’s a more risky venture, clarity will help gain the support of the organisation. If we’d had a stronger case in this sense, we’ve had got more acceptance from the business.

Communication groups: • Have a key working group – the group reviewed it, approved it and then drove the success of the business case to ensure the right approvals were sought. • Get input from across the business – keep the group defined but have we input from the key stakeholders within the organisation up to executive level. • The one thing I think that we could’ve done better is have our Chief Financial Officer engaged in the group earlier. We had business managers, financial business managers engaged and working as a part of it, but the Chief Financial Officer for the organisation probably could’ve been communicated with in the group right from the start.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST

Healthcare:

Why Human Resource Practices Are Flat-lining As providers of essential services and places where people’s lives are literally on the line, hospitals are commonly expected to be best practice workplaces, set apart by good management, effective leadership, and engaged and motivated workforces. But the management of hospital workers has not been rigorously researched.

ustralia has probably one of the better healthcare systems in the world, if not the best, notes Patrick Bolton, the director of Clinical Services (Medical) at Sydney’s Prince of Wales Hospital. Australian government spending on health is around the average of other developed countries, according to a comparative league table. “Yet when you talk to people who work in the healthcare system, they say it stinks,” says Bolton. He believes the federal government has caught up with the fact there is dissatisfaction within the ranks, but not the actuality of what is happening inside hospitals. That’s about to change due to a collaboration that joins business school thinking with health management and clinical practice. Julie Cogin, a management professor at the Australian School of Business leads a research team with Ian Williamson, a Melbourne Business School professor, and Bolton. They are investigating how healthcare workers experience management and how that affects productivity and patient care. The research will shed light on what can be done to improve health workers’ satisfaction and boost health outcomes for patients. Cogin and Williamson have both previously investigated human resource management in the commercial and not-for-profit sectors, and have been spurred on by a lack of empirical research outside of the business world,

particularly in relation to hospitals. “It struck us as odd that we have all this information on how, for example, accountancy firms or law firms can be best managed, yet we hadn’t looked in a systematic way at how effective management could influence healthcare outcomes,” says Williamson. The project is timely due to the federal government’s new plan to create a nationally funded but locally staffed single hospital network to replace eight separate state and territory systems. And previous indicators suggest there’s significant room for improvement.

On the Brink In 2008, the Australian Commission on Safety and Quality in Health Care published a report that exposed problems with patient safety in hospitals. Subsequently, commissioner Peter Garling’s report into acute care services in New South Wales (NSW) public hospitals made 139 recommendations for change, portraying a health system on the brink with many hospitals in deficit, and recruitment often frozen or delayed, putting existing clinicians under additional stress. The NSW government’s response was to commit an immediate A$485 million to implement Garling’s recommendations. But the commissioner also identified problems that didn’t require funding solutions. Garling’s

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

report was highly critical of the culture in hospitals, highlighting a lack of good communication between clinicians and management, a hierarchical top-down structure that often led to bullying and an administrative workload that left doctors feeling bogged down. NSW wasn’t alone in revelations about demoralised healthcare staff. In 2009, Cogin’s research revealed increases nationwide in workplace conflict and bullying. Adding to this picture has been the ongoing, chronic shortages of nurses, doctors and other healthcare professionals that are behind the current nurses’ dispute over nurse-patient ratios and their impact on patient safety. Various research papers have linked understaffing to patient mortality and illness, accidents and near misses, all of which can cost the healthcare system up to A$2 billion a year, according to the National Health & Hospitals Reform Commission (NHHRC). This figure does not take into account the impact on staff morale, high turnover and the increased cost of hiring and training new staff, using temporary workers and paying overtime costs. “There’s a tremendous amount of pressure to use money well and you can’t waste it on bad bets,” says Williamson. As a hospital’s largest expenditure is staff-related, the research can point where best to use funds to generate the greatest return such as the types of training opportunities, and who to hire.

TOPICS OF INTEREST The way that workers are organised in a hospital has an impact on how an employee experiences the work and also on the effectiveness of patient care, Williamson says. “For example, when you have a patient with multiple complaints, it requires collaboration across experts,” he says. “Doctors are knowledge workers and their training rarely provides opportunities to collaborate with other experts. It’s not just a healthcare problem, it happens a lot in research and development (in other organisations) and in law firms. It’s a management problem and has a big impact on the effectiveness of the organisation. Managers need to be more savvy about the social capital they have in their units.” Key questions to be scrutinised by the researchers include: Are human resource management systems working to the extent that healthcare workers feel supported, have trust and feel commitment to their job? Second, how does good – and bad – human resource management (HRM) influence the quality of healthcare provided for individuals and at an organisational level? A benefit of this study is that one of the partners, Queensland Health (QH), has provided unprecedented access to proprietary data on sensitive measures of hospital performance, including mortality rates, bed waiting times, errors, re-admissions, patient satisfaction and engagement. For this reason, Queensland will be the initial focus of the research and, says Cogin, “we should be able to say with some certainty what’s working and what’s not working.” Queensland Health centrally manages its data, measuring performance in all its hospitals across the state. Data is collected quarterly. Not all states have such comprehensive and coordinated data collection of hospital performance.

Factoring in Variables There are a lot of variables between hospitals, so how does the research team approach such a multi-faceted problem head on?

Cogin agrees the size and location of a hospital is relevant to its people management practices. “A small rural hospital in northern Queensland will have a completely different context to a hospital in urban Sydney,” she says. “The resources and talent available are very important to consider.” Williamson says one of the major problems hospitals face is the ability to attract and retain talent – and retaining staff so that they’re not burning out is an extremely difficult job. Rural hospitals in particular struggle with this. The study will begin by meeting executives who have to cope with such problems in three different types of hospital: a metropolitan or large teaching hospital, a medium-sized facility on the fringes of a city and a rural or regional hospital. “We want to look at the types of strategies they employ,” says Cogin, “and the demands they face such as funding, patient issues, talent available and their strategic orientation.” The next stage will be interviews with a sample of department heads and managers – they may be from oncology, cardiology, physiotherapy or the nursing unit. Cogin says the idea is to look at how they work, identify successful practices that achieve the best results from their staff and also the opposite – what they don’t do well. “In this way we will find out what strategies work in developing trust and motivation with clinicians such as nurses, doctors, physios and pharmacists.” In the third part of the study, the researchers will work closely with the professional healthcare staff to find out the elements of their job that have positive and negative effects on them. Whether, for example, they feel valued, whether there are reward systems in place, and how rostering occurs. It isn’t just a one-way process, Williamson says. While the researchers will be conducting qualitative investigation by talking with physicians and managers to discover new insights, they also hope to use prior research to address some of the problems they find. “We definitely come into this with some

clear theory that works,” Williamson says. “There are proven leadership behaviours that are effective at leading staffs of knowledge workers. But we anticipate seeing a lot of variance across hospitals: some managers will be doing them, some will not.” Where Cogin and Williamson find successful people management practices, they will be tested for efficacy. “Let’s say we have a manager who says, ‘This is the way I like to lead and the behaviours that I engage in with my staff and that’s why my patient satisfaction and staff retention is so high,’” Williamson says. “We’ll measure those behaviours and see if another manager engaging in those same behaviours realises similar patient satisfaction levels and employee satisfaction levels.” Bolton believes the relationship hospital healthcare workers have with their managers is different to other industries, and the role of a healthcare manager is to be invisible; to make it possible to get out of the way and let the professionals get on with the job. “What a doctor really wants to do is the doctoring,” he says. Williamson agrees that hospital managers don’t come in and mandate like in other industries. “A hospital unit head has to be able to influence [productivity] in other ways by shaping the way in which people engage,” he says. “It’s not unique to hospitals but it’s quite critical in them.” The research results are keenly anticipated by the industry partners – Queensland Health, the Australian Healthcare & Hospitals Association (AHHA) and the South Eastern Sydney and Illawarra Area Health Service (SESIAHS). Cogin says it will help them “to achieve their strategic objectives of recruiting and retaining qualified healthcare professionals and providing an organisational work environment that promotes wellbeing of staff and enhances overall hospital performance.” Source: Knowledge@Australian School of Business Published: February 14, 2011

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TOPICS OF INTEREST

Contractor Management DAVID J. RANDALL I B.SC., B.ENG.(HONS.), DIPBUS, DIPMGT, M.I.E.AUST.,C.P.ENG., C.F.S.I.A., R.S.P.(AUST.), RABQSA CERTIFIED AUDITOR, JP(QUAL), MANAGING DIRECTOR. DRA SAFETY SPECIALISTS

Abstract This paper discusses the new requirements for the management of contractors (focusing on construction activities) under the harmonised legislation introduced on 1 January, 2012. The paper then reviews the current contractor management systems that have been implemented by various companies consulted to by DRA Safety Specialists. With over 22 years experience in developing and managing Safety Management Systems for medium to large size corporations, the contractor management system has undergone possibly the most change to comply with the ever increasing requirements imposed by the Regulator. Although the full contractor management system is not part of the paper, basic guidelines to what is required by companies is provided.

HARMONISED LEGISLATION Work Health and Safety Act 2011 Review Duties of Care – Businesses and contractors will now be persons conducting a business or undertaking (PCBU) with duties clearly defined under the Act. The current obligation of a Principal Contractor (PC) under the WHS Act 1995 (QLD) was repealed on the 1st January, 2012 and hence, all contractors working for a business irrespective of their appointment as a PC who fail to meet their duty of care requirements will be prosecuted as a PCBU. WHS Regulation 2011 Review Construction Project – A construction project is one that involves construction work where the cost of construction work is $250,000 or more -refer WHS Regulation 2011 s292. Principal Contractor – A PCBU commissioning a construction project can engage another PCBU as PC for the construction project, and can authorise that person to have management or control of the workplace and discharge the duties of a Principal Contractor – refer WHS Regulation 2011 s293. Note – there can only be one Principal contractor at any specific time. The PC will also be required to comply with the WHS Act 2011 S20 regarding duties of a PCBU involving management or control of workplaces. Note: The Form 34 – Appointment of a Principal Contractor ceased to exist on 1st January, 2012 and appointment of a Principal Contractor will be through normal contractual arrangements. Safe Work Method Statements – If a PC has been appointed by a business then the PC is required to obtain copies of safe work method statements (SWMS’s) for high-risk construction

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

work before that work commences -refer WHS Regulation 2011 s301. It is the PCBU’s responsibility i.e. the contractor working for the PC, to review the SWMS and keep a copy of the SWMS. The PC must obtain a copy of the SWMS’s for all highrisk construction work -refer WHS Regulation 2011 s312. The PC must ensure the contractors compliance with the SWMS. WHS Management Plan – the PC must prepare a written WHS Management Plan before work on the project commences. The details of that plan are specified in WHS Regulation 2011 s309. The PC must, so far as reasonably practicable, ensure that each person on the site has been made aware of the contents of the WHS Management Plan before commencing work. The plan must be reviewed to ensure it remains up to date -refer WHS Regulation 2011 s310 & s311. If a notifiable incident occurs, the plan must be held for two years after the incident occurs. General Construction Induction – The PC (and all other PCBUs related to the project) must ensure all workers employed by them hold a current general construction induction card. (Must have performed construction work within the previous 2 years). Specific Risks – the PC is also responsible for the storage of materials and waste, the storage of plant that is not in use, traffic management in the vicinity of the workplace and essential services at the workplace. Amenities – The PC is required to provide the amenities as detailed in WHS Regulation 2011 Schedule 5A and ensure they are maintained in hygienic serviceable condition. In addition to the above requirements there are a number of elements in Part 3.2 and all of Part 4.4 of the WHS Regulations 2011 that are required to be complied with by the PC. For example, the PC is required to provide workplace facilities, first aid, emergency planning, PPE, management of chemicals etc. This is in addition to all the other duties of a PCBU which are detailed within the WHS Regulations 2011 i.e. noise management, electrical compliance etc.

Legal Duties Defined Before a Contractor Management System can be developed it is important to clearly understand the legal duties a PCBU has for a contractor working for the business. This legal duty of care requires a company as a PCBU to ensure, so far as is reasonably practicable, that the health and safety of other persons is not put at risk from work carried out as part of the

Futurebrite™ Technology conduct of the business or undertaking – refer WHS Act 2011 s18.

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Under the duty of care requirements a business is required to ensure that its workers, which include contractors, carry out their work in safe premises, using proper and safe plant and substances, employing systems of work that are safe, and in which there has been adequate, training, instruction or supervision– refer WHS Act 2011 s19. This duty applies to each and every aspect of work to be carried out by a worker or contractor. However, it is also the contractor’s duty to ensure these duties are fulfilled for their own employees and subsequent sub-contractors – refer WHS Act 2011 s20-s26.

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The duty is also owed to other persons who may be affected by what a business does, and will be higher where the location at which the work is performed is under the management or control of a business. Any attempt to exclude, limit or modify the operation of the WHS Act 2011 or any duty owed under the Act or to transfer to another person any duty owed under this Act will be void – refer WHS Act 2011 s272. This means that imposing responsibilities on a contractor in a contract will not remove a duty that is already owed. A business also has a legal duty to ensure that no person is exposed to risk from the way in which their business is operated, even those with which there is no direct or formal relationship e.g. members of the public. This duty requires a business to monitor and regulate the conduct of the contractor whilst working to ensure that their work does not place the safety of others at risk. For example, should a contractor be working at height and drop equipment which strikes a member of the public visiting the site, both the business and the contractor may have breached their duty of care for failing to established suitable controls to manage this foreseeable risk. Had the business required a SWMS for working at height that included controls for falling objects, and reasonable steps were made by the business to ensure compliance with the SWMS, and then the contractor subsequently removed those controls which allowed the incident to occur, then the business would be in a defendable position that they had done what was reasonably practicable. Having the management or control of a workplace sees a duty to monitor that the workplace and means of access and egress are safe and without risks to health. In some circumstances a business may be considered to have duties of management or control of the workplace even though a contractor has the practical day to day control of it. In the event an incident occurs and the Regulator arrives to investigate, the outcome will rely heavily on the contractor management documentation produced by the business to manage the risks. Ultimately a business may be liable for prosecution for a failure to manage health and safety at work, where their reckless conduct results in a risk of injury to others. Apart from any financial penalty, the community outrage as a result may be detrimental to the ongoing success of the business.

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TOPICS OF INTEREST CONTRACTOR MANAGEMENT SYSTEMS Depending on the type of contract and the level of risk associated with it, the engagement of a contractor must be supported by a safety management system or safe method of work that clearly identifies the safety requirements of the contractor and the business. The standard process DRA Safety has adopted when assisting a client develop a Contractor Management System has been to follow the five important stages of the contracting process in which health and safety issues must be considered: Contractor Management Systems Pre Harmonisation Within small to medium sized businesses where contractors are predominantly used for the maintenance of plant, equipment and buildings etc, a procedure was developed which required contractors to provide the following information before commencing work:

• Contractor licenses to undertake the work; • Insurance coverage in both Public Liability, WorkCover and Professional Indemnity (if applicable); • Completion of a “minimum standards document” that sets out the minimum requirements expected of contractors whilst working within the business. When a contractor arrived at these businesses they were required to: • Be given a brief induction which was recorded on an induction check-sheet; • Receive a contractor’s visitors pass which was worn whilst onsite to clearly identify them from other persons; and • Sign-in the contractor’s register which identified whether they were undertaking any work that required permits and to acknowledge that they have read the asbestos register for the site. This simple system was working effectively for the management of non- construction

contractors for businesses prior to the introduction of the harmonised legislation. When a major construction project was initiated at these workplaces, the company would appoint the builder as Principal Contractor who would then have the obligation to manage the safety of all persons on the construction site. The only obligation for the client was to consult with the Designer, Project Manager and Principal Contractor on how risks associated with the project could be minimised, and provide any information about hazards and risks relating to the site that they were aware of – refer WHS Act 1995 Section 30B. With the harmonised legislation, this ability to transfer the liability for the management of safety on a construction site by the appointment of Principal Contractor using the prescribed form has been removed. This new joint PCBU responsibility on a site has created some confusion in industry, however, the basic premise of law that I always espouse is that “you should only be held liable

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TOPICS OF INTEREST over that which you have control”. To explain this I refer to the engagement of an electrician to perform electrical work at your business. The business has control to ensure they are licensed, carry appropriate insurance, have been inducted to the hazards in their workplace etc, but not how the electrician performs the electrical work. Contractor Control Systems after Harmonisation To satisfy the requirements of the new harmonised legislation contractor management systems have been reviewed to include all the requirements pre-harmonisation and have added the requirement to identify the level of risk associated with the contractor’s work, which will then determine the level of interrogation into the safety capability of that contractor. Utilising a risk management approach such as this allows contracts involving work which may pose a significant risk to health and safety to be identified, assessed and controlled appropriately. It is therefore important to review the Contract Risk Classification system that has been developed for DRA Safety Specialists clients. Contract Risk Classification Contracts are classified as high or low risk depending on the level of risk of workplace injury or illness associated with the activity being conducted. High Risk Contracts Contractors considered for high risk contracts are expected to demonstrate a higher level of development of their WHS management system than the low risk contracts. Contracted works are classified as high risk if they pose a significant risk of serious injury or illness. High risk contracts may involve any of the following tasks or conditions, but are not limited to: • Construction work; • Maintenance work; • Working in confined spaces; • Working at a height greater than 2 metres; • Demolition work; • Working with asbestos; • Working with gas; • Electrical work; • Use of hazardous substances;

• Excavation work; • Use of subcontractors; • Contract value exceeding $250,000 Other contracted works may also be classified as high risk if significant risk is identified at the conclusion of a risk assessment. For high-risk activities the contractor will be required to produce evidence of their safety management system by completing questionnaires and providing evidentiary documentation that the safety elements have been implemented. This system will then be supported by ongoing monitoring of the contractors through a formal auditing process to ensure their compliance with their safety management system (SMS). For companies, such as Rio Tinto concerns in Gladstone, contractors are required to be externally audited by a recognised safety professional against a Rio Tinto based audit tool. The audit tool assigns a 40% weighting to the desk top audit of the SMS, and 60% for the implementation of the SMS by the contractor. The requirement for licenses, insurance and a low LTIFR are also determined and if not met will automatically prevent the contractor from working on the site. The audit is paid for by the contractor who is then provided a

certificate of compliance by the auditor which they can present with any tender work to Rio Tinto. These contractors are then monitored by contract supervisors when conducting work and noncompliances are recorded and issued against the contractor which will affect their future ability to tender for work. For some companies and state government departments, any construction work over $1million requires the implementation of the QLD Department of Works system which requires the contractor to appoint an accredited Pre Qualification Construction (PQC) auditor. This system will require the successful tenderer to undergo a Safety Management System Audit and regular compliance audits at their cost, and the audit reports are forwarded to the business and the Contractor. Noncompliances identified must be rectified within agreed time-frames, otherwise penalties apply, and for gross breaches, contracts may be terminated. This process has worked very effectively for the Queensland Government in the recent Education Construction (BER – Building Education Revolution) Program and has now been instituted into the private sector. Low Risk Contracts Low risk contracts are those where there is low to negligible risk of workplace injury

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST or illness associated with the scope of operations. That is, it is unlikely that a significant injury or illness could occur during the contracted work, for example, labour hire of administrative staff. It should be noted that operations where hazards are controlled to minimise the risk are not classified as low risk unless the hazard has been eliminated. For example, the use of harnesses to control the risk of falling when working on roofs would still be classified as a high risk contract. The approach adopted for minor contracts should focus largely on undertaking a risk assessment of the work involved in the contract, ensuring that risks are suitably identified and controlled. Generally for low risk contracts, the contractor will be required to supply copies of licenses to perform work (where applicable), appropriate insurance coverage for the work undertaken, ensure staff complete the induction requirements of the work place, SWMS where requested. The contractor’s work performance and compliance to legislative requirements should be monitored by the Contract Supervisor using a spot check audit sheet, and any non-compliance recorded against the contractor which may affect their ability to be re-engaged. Management or Control of a Workplace Following the Contract and Risk Classification Matrix a contractor may be assigned Management or Control of a

Workplace. This process will require additional instruction to other workers in the area to ensure that they do not encroach on the contractors work area and that contractors ensure that this demarcation is maintained. This process of assigning Management or Control of a Workplace must be documented in the Contractor Agreement to ensure both parties are clear on who is responsible should an injury occur which results in prosecution or a civil claim. Recent work on developing contractor management systems for clients has resulted in the development of a Contract and Risk Classification Matrix; refer Appendix A, which will guide the Contract Manager to a procedure which then details the steps and forms that must be completed for the engagement and management of the contractor. The development of this risk classification system does add some simplicity to what may otherwise be a complex process. Recommendations for Businesses For most businesses the following contractor management systems are recommended for consideration. • Develop a contractor management procedure for inclusion in the Safety Management System to outline the businesses requirements for engaging contractors utilising a contract risk classification system as described in this paper to determine the necessary steps to manage the risk. • For major construction work where the contract value is over $250,000 and a PC is appointed, the PC should be required as a condition of engagement, to have their safety plan audited by an external safety professional who will provide a certificate to the business to say that the WHS Plan complies to the legislative requirements. • For major project work over $1M the Department of Works system which involves accredited PQC auditors should be instituted. The development and implementation of a comprehensive Contractor Management System will provide part of the necessary “due diligence” defence required after a contractor is injured at your workplace and the Regulator is investigating which PCBU “had control” and whether they exercised that control. To assist with the development of these systems please use a certified Safety Professional (CPMSIA) with a track record in the area of systems development. NOTE: DRA Safety Specialists Pty Ltd consultants are all Registered Safety Professionals with the Safety Institute of Australia and can assist your organisation with developing professional Contractor Management Systems, or developing a fully compliant online Safety Management System compliant to AS4801 with tablet based tools and forms to simplify the WHS compliance process. Please refer to our web site for full details of our services: www.drasafety.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

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TOPICS OF INTEREST

OHS:

how to plan it, fund it & get everyone onboard

Carl Sachs I Managing Director, Falls Prevention Specialist workplace access & safety

Dealing with one of safety’s toughest challenges – funding projects on worksites that senior managers never see – fall prevention specialist Carl Sachs has also become expert at attracting funding for OHS. Here, he shares the secrets of successful investment in safety. Where OHS meets business OHS professionals tend to be idealistic, as they should. Capital expenditure decision makers, on the other hand, are often a tad more hard-nosed. Both find the other’s approach immensely frustrating and that can be a big problem when it comes to funding safety-related capital-intensive projects. Surprisingly, the secret to finding common ground lies in the OHS professional’s stock in trade, the risk assessment. The pure logic of combining probability with

consequences to assign a risk rating is something that resonates with many senior company officers, who are increasingly attuned to risk management in an uncertain global business environment. The key is to present the information in a format that very clearly reflects the organisation’s objectives, whether they are prudent corporate governance, reputation management or sheer compliance. Create a plan The place to begin is with an audit. Uncover and document what the organisation already has in place and

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

the current compliance gaps, then set a baseline for improvement. At the heart of the audit lies the risk assessment’s matrix of the probability of injuries and their seriousness. This ranking system creates a list of priorities takes the first step towards legal compliance and successful corporate communication: accurate documentation of the facts. And while documentation is a necessity, do not be tempted to produce a daunting wad of paper designed to strike fear into the hearts of senior management. Clarity

TOPICS OF INTEREST hierarchy of controls – tends to work well for corporate accountants since the lowest order control for any risk is also often the cheapest over its lifetime.

is the secret to winning capital expenditure approval. For this reason, Workplace Access & Safety’s audit reports are presented very simply. Photographs of each hazard are matched with plain English explanations and a colour-coded risk rating. The results are summarised in tables and even the most time-poor decision-makers rapidly appreciate the relative urgency and importance of projects.

From a management perspective too, the most complicated safety systems are generally the least effective. Any fall prevention system that involves a harness, for example, also brings the need for second workers, rescue plans, regular inspections and a tide of paperwork. Sadly, this is where many facility managers face their greatest challenge. The main source of information about controls is equipment vendors, who are also generally enthusiastic promoters of complex, expensive solutions.

Illustrating reports to demonstrate hazards is particularly valuable when the decision makers are physically remote from the hazards. In our experience, prominent hazards are normally dealt with more rapidly than others that may be associated with greater risk but are quite literally “out of sight and out of mind”.

Remain stubbornly true to the hierarchy of controls and, almost invariably, there will be significant lifetime savings and safety gains to be won. Such practicality will also win OHS professionals many friends at the executive management level and invaluable respect from users.

Do the sums The next step is to team the prioritised areas with controls that minimise risk and maximise safety. Again, the good news is that the safety professional’s best friend – the

So, how then to get the safest, most workable solution and a proper costing? Choose your providers with great care. Look for those who participate at an industry level, are trainers, who provide impressive referees and, importantly, have a suite of solutions on offer so they can supply the appropriate match for your circumstances. Ask to see sample reports in advance and, for a real insight, learn how they manage their own safety obligations. Photocopied safe work method statements (SWMS) for a height safety installation, for example, warn that a service provider’s safety credentials are little more than skin deep. Specialists are normally best geared up to the job correctly and can often deliver savings due to greater efficiencies. Match the costings with the priorities identified by the risk assessment to create a budget. Of course, no organisation can realistically address all risks instantly, so the

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TOPICS OF INTEREST budget could have several phases to allow for systematic project management.

of commerce advisor and now OHS consultant Jo Kitney explains.

How to fund OHS systems

“Meeting health and safety obligations is a moral as well as legal obligation; however there can be differences in values and beliefs for health and safety between organisations and within organisations,” Ms Kitney says.

With a risk assessment and a budgeted list of priorities, the business case for OHS capital expenditure now simply needs a rationale. In most cases, compliance with safety obligations alone is sufficient but not always. In the name of flexibility, most work health and safety laws are open to interpretation and sometimes even conflict with other mandates. It is also true that many substantial safety gains are made beyond mere compliance in terms of productivity, lower insurance costs, improved morale and fewer lost time injuries. The most compelling call to action is the one that best mirrors the goals of your organisation as former chamber

“Decisions made by employers and business managers can be influenced by what they think and how they feel – and this can make the difference between resourcing health and safety, or not. “To find money for health and safety means looking beneath the line and establishing the organisations’ value base for health and safety. It is difficult to do so, but there are times when below the line aspects of health and safety management have to be challenged, to ensure that those making decisions are aware of the implications – personally as well as for the wider organisation.”

Get everyone on board Even the most robust safety systems come unstuck unless the people they are designed to protect take them seriously. Ensure that employees and contractors of varying skill levels are working safely by following a few basic principles.

Consult with users The first is clearly to consult with the users of any safety system very early and often throughout the process. An unworkable safety system is a dangerous safety system because it forces users to take perilous short cuts. A safety system that is difficult to manage is similarly frightening, so it is important to consider the resources and skills of the people using the equipment – right from the start so safety is inherent in the design rather than an afterthought. In Workplace Access & Safety’s field of fall prevention, for example, a vertical ladder line may suit a telecommunications environment where two riggers are working, trained in rescue

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TOPICS OF INTEREST and doing this on a daily basis. Not so for a school where teachers or grounds staff climb on the roof to retrieve balls. Apart from skills and resources, the conditions of use need to be understood. If people need to carry tools onto the roof, for instance, a narrow opening presents an added hazard. It is also important to make sure a truly representative group is consulted, which might go beyond the normal workplace boundaries. Employees might carry out completely different tasks to those of contractors and visitors, who are equally as entitled to a safe environment. It goes without saying that design concepts should be shared with and approved by users to ensure a sense of ownership as well as real-world functionality.

Training and Protocols Many of the most successful OHS projects require little or no training because they build safety into existing processes. On the other hand, some require serious skill levels

coupled with careful administration to make them effective. Beyond the skills of the user, work positioning systems, for example, demand inductions, administrative controls, rescue plans, a buddy system and regular inspections. It is essential in situations like these that users and the administrators responsible for the management of the safety system are well supported with training.

Management Feedback Don’t forget to include senior management – the people who approved the project – when it is time to celebrate project outcomes. Update the proposal document to create a review report, complete with before and after pictures and testimonials from users. Feedback in this format will be very welcome, builds a useful relationship for the next OHS project and is a great way to demonstrate compliance with your friendly workplace safety authority inspector.

OHS Skills are Great Business Skills OHS is often perceived as a cost rather than an investment and a tangled web of red tape. Ironically, occupational health and safety professionals are better equipped than most to present a compelling business case for capital expenditure. Like so many things, the key to success may just be simplicity.

About the Author Carl Sachs is the managing director of falls prevention specialist Workplace Access & Safety and takes an active role in the development of fall prevention standards, representing the Master Builders Association on the committee for AS 1657 – 1992: Fixed platforms, walkways, stairways and ladders – Design, construction and installation. Carl is dedicated to building a general awareness of this highly specialised area of risk, training facility managers of major retail corporations and regularly addresses OHS professionals at national conferences.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST

The Next Step

BIM’s role expands as facility managers take ownership Brian P. Skripac I AIA, LEED AP BD+C

A recent McGraw-Hill Construction SmartMarket Report on “The Business Value of BIM in North America” highlights growth in the adoption of building information modelling (BIM) systems in the design and construction industry from 28 percent in 2009 to more than 70 percent in 2012.

oreover, the use of BIM by building owners has increased from 18 to 30 percent over the same period and an even greater margin of growth is expected by 2014. And, with this continued adoption comes a level of BIM maturity where almost two-thirds of BIM users reported a positive return on investment. As early adopters of BIM technology, health care organisations and other institutional building owners are key players in expanding the role of BIM from its design-construction application to a facilities management tool.

Collaborative platform A widely accepted definition of BIM comes from building SMART alliance and the National BIM Standard–United States, which describes BIM as “a digital representation of physical and functional characteristics of a facility” and “a shared knowledge resource for information about a facility forming a reliable basis for decisions during its life cycle.” The definition continues: “A basic premise of BIM is collaboration by different stakeholders at different phases of the life cycle of a facility to insert, extract, update or modify information in the BIM to support and reflect the roles of that stakeholder.”

By virtually building the project before starting physical construction, design teams can identify and solve complex issues, share information quickly and effectively, and offer a robust BIM deliverable that is particularly applicable to the nuances of the health care industry, where continuity of information with BIM is critical to the translation of relevant building data downstream. This continuity, or the interoperability of information from one project stakeholder to the next, is an important component to the increased adoption of BIM, and one that is even more significant for hospital facilities managers who are looking to use the information-rich models being developed through the design and construction process. The importance of this concept has been well-documented by the National Institute of Standards and Technology (NIST) GCR 04-867 “Cost Analysis of Inadequate Interoperability in the U.S. Capital Facilities Industry” report, which estimates the cost of inadequate interoperability to be $15.8 billion per year. Of these costs, two-thirds are borne by owners and operators, most of which are incurred during ongoing facility operation and maintenance (O&M) and can be summarised into an annual cost of approximately 23

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

cents per square foot per year through avoidance, mitigation and delays.

Getting started With this landslide of information on the value of BIM, it’s not surprising to see health care providers beginning to define how BIM will impact the work they do. However, BIM is not a one-size-fits-all solution. Design and construction professionals often find that they are required to deliver a building information model at the end of a project. This is an extremely openended request that could provide a range of outcomes, many of which may never suit the intended needs of the end user. This is why starting with the end in mind is a critical step for a health facility manager. While anticipated use of BIM might simply be to track or manage space in an existing software application, its implementation isn’t quite that direct. For example, how will the delivered model integrate into the existing facility management software, if at all? Does the model possess any of the data to be captured by the hospital, and is anybody at the hospital able to open the building information model? Figuring out all of this BIM technology and integration might seem to be a monumental task, but collaboration with a BIM-savvy design and construction

TOPICS OF INTEREST professional can provide direction to accomplish this transformation. Rather than trying to embark on this alone, health facility managers should take advantage of the group of trusted advisers with whom they already are working. Many of these team members have experienced the ups and downs of implementing BIM within their organisations, and most have probably used these technologies on a project they’ve previously delivered for the organisation. This partnership can prove to be extremely valuable in helping to understand the technologies being used to create building information models, and the best way they can be integrated into a hospital’s systems. There can be a wealth of building, systems and space information available for use within BIM, but if the data aren’t relevant to an organisation, it quickly can become difficult to manage the burden of a data dump at the completion of a project. A focused collaboration between design and construction professionals and the health care organisation can provide an opportunity for the organisation’s representative to say, “This is the information I need,” and have the professional identify how it should be incorporated, structured and formatted into the model for reuse downstream.

Managing the technology The post-occupancy incorporation of building data into an existing system long has been a tedious and error-prone process that now can be automated via the model’s geometry and data, if structured and formatted correctly. Health facility managers are seeing the value of BIM by integrating it into their existing computerised maintenance management systems (CMMS) and computer-aided facility management (CAFM) systems as well as energy or building management systems and electronic document management systems. By not limiting the application of BIM to simply a technology-totechnology interaction, the realistic outcomes that can be achieved by this type of workflow become evident. Often considered low-hanging fruit is BIM’s ability to integrate into a space management system. BIM applications such as San Rafael, Calif.-based Autodesk Inc.’s Revit Architecture are capable of tracking building spaces and easily categorising that information into departmental areas as well as floor-to-floor or building-by-building breakdowns across a larger medical campus in both graphical and schedulebased interfaces. This information, with a little formatting and collaboration, can be used to

provide a deeper insight into facility use, space utilisation and potential renovation planning. In addition, this data can be leveraged to track leasable space as well as quantify areas to be utilised in Medicare and Medicaid reimbursements. Having this information readily accessible at a higher level of accuracy than before can bring immediate financial impacts to health facility managers. Expanding beyond just space, facility managers also are able to capture asset information that can be useful in the ongoing operations and maintenance phases of the building’s life cycle. With an advanced asset management strategy in place, health care organisations are taking advantage of more detailed preventive maintenance schedules on major building systems and equipment components. Integration into work order management systems allows facility team members to pull up a virtual model to query a specific building component or equipment item, with full access to its O&M, submittal, commissioning and warranty information, so they can be prepared to address problematic issues as they arise. This ability to access model geometry can provide a continual powerful interface for locating and accessing above-ceiling or behind-wall conditions throughout a hospital. Architects and contractors are delivering robust asbuilt models at the completion of a project, which can be relied upon for future use. Coupled with the power of mobile devices, geo-referencing and radio-frequency identification tagging of assets, BIM provides a high level of certainty, accuracy and reliability that can expedite the work effort across complex health care facilities. BIM’s visualisation capabilities often have been characterised as “Hollywood BIM” by design professionals, but its value should not be ignored by health facility managers and administrators. In its simplest terms, a model’s power to visualise space can contribute to staff and patient recruitment.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST Imagine if a health care organisation is able to share a design team’s visualisation of an upcoming labour and delivery suite to persuade expectant mothers that a hospital is the ideal location for the birth of their children. Future facility growth and expansion can be highlighted to show a hospital’s commitment to the community of delivering superior health care. Administrators also are taking advantage of BIM as a recruitment tool to show potential physicians and researchers that they have space and resources available. BIM also can work to improve visitor wayfinding. Visualisation should not be limited to geometry, but should be inclusive of its underlying data, which can greatly impact life safety documentation and Joint Commission compliance. Having a model in place and being able to highlight critical fire-rated partitions before embarking on a planning or renovation project can provide a unique visual insight to a building. Additionally, the ability to maintain building geometry and data within BIM can provide immediate access to information that can help avoid costly downtime that might occur if the facility is not being properly maintained before a Joint Commission survey. Sustainability is another opportunity for health facility managers to take advantage of BIM’s interoperability. Many hospital administrators and facility managers are exploring energy audits to better understand how buildings are using energy, but this tends to capture only historic information. However, when these data are combined with an energy model — which quickly can be derived from BIM — health facility managers can investigate why a building may not perform as designed. Comparing this analysis with the audit data can bring significant value when planning future capital improvements.

Managing the process With all of these BIM-enabled opportunities available for health facility managers, the planning and

implementation process is a critical first step. BIM is not only a technological transition, but a cultural one as well. Budgets need to be created to invest in the necessary hardware and software, but facility managers also will need to consider investing in their facilities team. Collaboration with design and construction professionals at the beginning is key to setting a foundation for a health facility manager’s BIM implementation plan, but it’s critically important to realise that implementation will be ongoing. Questions such as who will be the internal BIM champion within the organisation, who will manage the models after they are turned over to the hospital, and who will be on the BIM-savvy team that will support this leader need to be discussed within the organisation. One person alone will not be able to manage BIM’s integration across an entire hospital and it will require support from an entire organisation to be successful. Once a leadership team has been defined, the team should look to understand which technologies will be utilised and what level of model development will be needed to implement BIM. There is a range of model uses and levels of development on the design and construction side of BIM, but those aren’t necessarily applicable to health care organisations and an internal process should be examined to understand the appropriate methodologies for a specific organisation. Consideration should be given to what information will be captured directly in the modelling applications to be managed internally as well as information that will be received at the completion of a project. Having this knowledge, combined with a specific CMMS or CAFM perspective, can help bring alignment to the tools and processes that need to be in place. As BIM adoption continues to grow, the standards and technology that support BIM are becoming more integrated. For instance, to facilitate the capture of essential building information

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

to support the design-build-operate life cycle of a facility, the Construction Operations Building Information Exchange has emerged as a growing industry standard for the formatting of model geometry and data. Neutral modelling formats and open standards continue to spark discussion about leveraging Industry Foundation Classes files as they become more relevant as a model exchange format between project stakeholders. At the same time, new “Lifecycle BIM” applications, such as EcoDomus and YouBIM, are emerging to more fully integrate CMMS and CAFM solutions into a data-rich, model-based interface with BIM as the backbone of the information being carried through to hospital facility managers. Ultimately, the solution to standardising model geometry and data formatting to facilitate delivery of valuable information to the new cloud- and mobile-capable life cycle BIM applications is engaging building owners in the development of BIM standards and guidelines.

Unique opportunities The ability to access more relevant and accurate information from anywhere in a facility with a visual geometric representation is bringing a high level of value to hospital facility managers across the country, which will only continue to grow. Similar to the way electronic health records are revolutionising hospitals, BIM is enabling health facility managers to have a single repository of building data in which information can be created, shared and reused. The opportunities will be unique to every organisation and success inevitably will be driven by the facility’s ability to fully implement the technology and process changes that BIM brings. Brian P. Skripac, Assoc. AIA, LEED AP BD+C, is director of digital practice at Astorino, Pittsburgh. He can be reached at bskripac@Astorino.com.

INDEPENDENT MONITORING CONSULTANTS – AUSTRALIA TECHNICAL PAPERS

INDEPENDENT MONITORING CONSULTANTS Head Office: 23–25 Daking Street North Parramatta NSW 2151 1300 131 405 (02) 9890 5067 New South Wales/ACT: Ian Hartup 0411 109 353 Queensland/NT: David Curry 0408 368 921 Victoria/South Australia: Steve Powell 0431 503 194 THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

ADVERTORIAL

Oxygen Reduction Fire Protection A Revolution in Fire Safety Australia’s first oxygen reduced fire prevention system was installed recently at the Sydney Adventist Hospital (SAH).

he system is called FirePASS® and it has the unique ability to create an environment of breathable, controlled oxygen reduced air that prevents fire ignition. FirePASS® achieves the ultimate goal in fire protection – fire prevention.

How Does FirePASS® Work? FirePASS® prevents fire proactively thereby eliminating damage and business interruption that occurs when suppressing a fire after it has already started. The key to the technology is that oxygen reduced (hypoxic) air is produced by partly filtering out oxygen from ambient atmospheric air. Normal atmosphere contains 21% oxygen. The air put into the protected space is 15% oxygen and 84% nitrogen (1% is made up of argon, carbon dioxide and other gases). A fire cannot start in this environment. Common flammable solid materials and liquids cannot be ignited with an oxygen level below 16%.

Hypoxic air environments are currently used for physical training and rehabilitation of athletes, as well as in medical research. ARA has engaged a well-respected Australian thoracic specialist, Professor Matthew Peters to conduct an independent review on working in hypoxic conditions. The goal is to develop a protocol for workplace safety. Hypoxic air has no detrimental effect on equipment. The oxygenreduced environment slows oxidation and is perfect for preservation of irreplaceable items such as museum exhibits, artworks, archived documents and rare artefacts.

The First Hypoxic Fire Prevention System in Australia The ARA Group entered into an exclusive arrangement with FirePASS® International AG, a Swiss company that invented this revolutionary fire prevention technology. The Sydney Adventist Hospital at Wahroonga in Sydney is a longterm client of the ARA Group’s fire protection company, Automatic Fire Protection. Darren Walsh, Automatic Fire Protection account manager for the SAH presented the FirePASS® fire prevention solution to Bernard Jakovac, Director of Engineering Services at SAH. Bernard could immediately see the benefits of a fire prevention system that would never let a fire start, compared to a traditional fire detection and suppression system.

Safe for People and Property

In June 2013, Automatic Fire Protection installed a FirePASS® FP500 System into a power factor correction room and a sub-main room at the SAH. The FirePASS® FP-500 System typically protects a volume of 500m3.

FirePASS® uses ambient air to produce breathable air for fire prevention. It is safe for people and safe for the environment. There has been extensive medical research in the UK, Europe and Australia to support the safety of working in a hypoxic environment of oxygen at 15%.

Bernard and the SAH have offered interested parties the opportunity to view the FirePASS® FP-500 System in operation. Several consultants and insurance providers have already visited SAH to see the system. Without exception, the response to the first hypoxic fire prevention system installed in Australia has been excellent.

At sea level, 15% oxygen content is equivalent, in terms of human physiology, to normal atmospheric air at an elevation of around 2,700 metres (9,000 feet) above sea level or being on a commercial flight. Millions of people around the world live at altitudes equivalent to exposure at or below 15% oxygen concentration at sea level.

ARA takes great pride in being innovative and introducing the world’s leading technologies to the Australian market. For more information on FirePASS® Oxygen Reduction Fire Prevention Systems, or to arrange a visit to see a FirePASS® system in operation, please contact Martin McGettrick, General Manager ARA Fire Special Hazards. Mob: 0425 357 422 | martin_mcgettrick@arafire.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST

Introduction to Operational Readiness National Conference Interactive Workshop Topic Jim Cozens I Dip. Eng. (Mech.), MIHEA, BHA, CHE, FACHSM, MISBE Chief Executive Officer Institute of Hospital Engineering, Australia

onstruction project turnover time is hectic. Facility operational readiness and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and commissioning-ready compliance at occupancy can put a hospital at risk during pre and post occupancy survey.

Challenges and limitations There are many challenges in health care facility commissioning. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimise the duration while meeting all statutory and regulatory compliance requirements by initial occupancy. Construction/renovation projects in an existing health care environment also must manage the commissioning readiness impact on existing facility operations. Whether or not the commissioning team members have other responsibilities, such as managing an existing facility department, team members will still face limitations during the commissioning process. These limitations can include the necessity to stop those variations which contribute to delay and added cost. Additional desired improvements that are not already in the project will probably not be able to be made without delaying acceptance. Committing to new procedures and standards beyond those required by the new facility increases

Source: John Weiser – Anatomy of the Hospital Project Life Cycle – OHA Planning Conference October 8, 2009

operational complexity and can delay occupancy. Facility commissioning readiness issues are both logistical and operational. Facilityrelated logistical planning considerations usually involve building turnover; acquiring, installing and commissioning new equipment and furniture; and moves and sequencing of detailed interrelated activities. Operational commissioning planning issues usually involve planning for the modified processes and practices that will be necessary in the new facility. These operational issues could affect all functions, departments and areas. They may be a result of intended changes or unintended consequences and will require detailed implementation to be effective.

Successful practices Professionals in the health care commissioning readiness field report

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

common success factors in successful facility commissioning. These include designating a commissioning project manager to bring about timely organisational cooperation, supported by multidisciplinary teams that have clear commissioning roles and responsibilities. The teams work together effectively to develop and integrate the necessary cross-functional processes. It is helpful for participants to have both meeting management and conflict management skills because of the volume of upward, downward and sideways communication. Other success factors include having clear project objectives supported by realistic scheduling and planning, along with consistent real-time communication and rapid decision-making. A “commissioning hot line” is also a helpful feature. Keeping commonly encountered commissioning issues in a database and publicising their solutions, as frequently

TOPICS OF INTEREST asked questions are often cited as factors in successful commissioning.

that they are available, still accurate and sufficiently cover the new infrastructure.

The Australasian Health Facility Guidelines (AusHFG) is an initiative of the Australasian Health Infrastructure Alliance (AHIA) and is proving to be a useful guide enabling planners and designers of health facilities throughout Australasia to use a common set of guidelines and specifications for the base elements of health facilities.

Training includes readiness for security incidents; issues with facility-related, clinical and other equipment and systems; all hazardous material and waste-related requirements; use of personal protective equipment in the new environment; and correct fire response procedures. Both facility staff and independent consultants and contractors will be trained in environment of care risks, incidents and reporting.

Proponents of the AusHFG claim these guidelines offer the following benefits: • Australasian best-practice approach to health facility planning; • access to standard spatial components; and • a highly flexible tool responsive to dynamic changes in health care. State Health Authorities also offer guidance through their respective central agencies which are readily accessed through respective agency websites.

Education and training Education and training are always important in health care facilities, but never more so than in new facilities or in newly expanded facilities where changes need to be understood. These changes can include new building systems and equipment. Training includes dry runs, drills and exercises on both clinical and utility systems issues, system-specific failure contingencies and other emergency management issues. User acceptance testing can take the approach of seeing how robust the new systems are by performing negative testing designed to “break the system” before the first patients are seen within the new project area. Even expansions and renovations require consideration. Training both users and maintenance staff is necessary on new equipment and technologies to reflect redesigned processes requiring new policies and procedures. Existing maintenance work orders could be outdated because of new technologies. New utility system and equipment configurations require updated component failure contingency plans. Earlier training materials should be updated to ensure

Finally, all designated personnel should be trained in emergency management functions and requirements.

Proactive compliance A corollary to the proactive avoidance acceptance testing approach would be “proactive compliance.” Rather than finding what is wrong and fixing it, proactive compliance involves determining what is needed and when it is needed for compliance, identifying what is missing in time to get it, then managing this process. Proactive compliance recognises that continuous compliance could include an unannounced accreditation survey shortly after occupancy—and some hospitals can attest that this has occurred. Regardless of survey timing, however, due diligence alone mandates full survey-ready compliance at occupancy. Proactive compliance includes identifying anticipated authority having jurisdiction (ACHCS) reviews and surveys along with their time frames. Activities and documentation can then be scheduled and completed to meet the time frames. The organisation should determine whether it can do all of the compliance work inhouse or requires some outside assistance. If outside survey readiness assistance is required it will have to be proactively managed to be completed on time. Some organisations may choose to have their own personnel focus on commissioning and turnover rather than detailed compliance activities, whereas others may choose to have their own personnel do all of the required compliance work before occupancy.

Organisations must identify all of the required compliance documentation as well as who on the project team is responsible for each item. Items that are not already on site or in situ will need to be arranged for and scheduled in time to support ACHCS or other statutory authority time frames, including a survey upon occupancy. The most effective approach is for compliance requirements related to the initial inspections, testing, documentation and training to be factored into project construction documents. This can ensure that project record documents are both survey-ready without more work by the agency and received on time to support an early survey. This leverages already scarce resources by ensuring that facility personnel do not need to spend time or funds during this extremely busy period redoing what the contractor typically provides to make it survey-ready. Proactive compliance also recognises that accreditation agencies are not just looking for project record documentation on that first survey—they may also look to ensure that the Construction/Refurbishment project’s impact has been accurately and fully defined in all activities, drills, exercises, management plans, policies, procedures, schedules, forms and related documentation.

Documentation required Compliance documentation is just as important on the day a hospital opens to receive patients as later in the facility’s lifetime. Unfortunately, all too many health care construction projects reflect one or more of the following conditions about some of the compliance-related project records: • The work never gets done; • The work gets done but is not accurately documented; • The work gets done and gets accurately documented, but does not meet statutory compliance rules; and/or • The work gets done, gets accurately documented, the documentation is acceptable, but it does not arrive on time for an early statutory or ACHCS survey.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

TOPICS OF INTEREST The following types of EC compliance documentation should be ready and easily retrievable for a survey: • Project record documentation such as test and inspection reports, permits, licences, certifications, documentation of all required “testing prior to initial use” and statutory approvals. • Documentation for the new facility or expansion such as inventories, management plans, , risk assessments, training records, maintenance decision processes, inputs into maintenance management systems from operation and maintenance manuals, evaluations, lists, spreadsheets, data¬bases, schedules and forms for ongoing required drills, exercises, tests, inspections and maintenance and all required emergency operations plan documentation. • Records regarding the “Life Safety Assessment” and accurate updated life safety plans, electronic statement of conditions any “plan for improvement” items and performance-based options for new construction or equivalencies for existing construction. Construction in healthcare and hospital environments pose dangers not only to contractors, but to hospital staff and patients. Interim Life Safety Assessments are occupational health and safety measures that are put in place to protect the safety of patients, visitors, and staff who work in the hospital. In simple terms we are talking about things like exit signs and pathways to an egress point, fire protection systems including smoke detectors, fire suppression, fire extinguishers and fire alarm systems, smoke barriers, emergency evacuation plans, in addition to many other items that contribute to the wellbeing and safety of occupants in the hospital or healthcare facility. Construction or maintenance activities will have an impact on the life safety systems in the hospital, thus requiring an Interim plan to address the deficiencies created by the work activity. Occupation Health and Safety Legislation compliance is critical in this regard as its purpose is to provide guidance and a framework to protect the safety and health of patients by compensating for hazards caused by construction activity. Other key elements in this regard include:

• Documentation related to, spill kits, monitoring equipment and other supplies. • Mapping of utility systems and labelling for critical utility disconnects. Additionally, systems and equipment, including life safety building features or components, must be commissioned and/ or tested prior to their initial use. It is not practical to list all such items here. Presumably, project record documentation that meets statutory requirements would be acceptable if they were available during a survey. The management plans, policies and procedures will reflect changes to facilities, areas, operations, infrastructure systems, equipment, processes and department locations or relocations. Risk assessments may be needed for safety, security, fire protection and where (if permitted) smoking is to be permitted. Risk assessments also are typically used to identify critical medical equipment and utility systems operating components. Risk assessments and the hazard vulnerability analysis are used as input to the emergency management plan. The areas of hazardous chemicals, hazardous medications, hazardous gases and vapours, radioactive materials, and hazardous energy sources (including radiation, lasers and batteries) often involve risk assessments. Written inventories include either all or selected subsets based upon risk of hazardous materials and waste, medical equipment (which requires evaluation prior to initial use) and operating components of utility systems (which require evaluation of new component types prior to initial use). A fire extinguisher inventory also might be created if that is considered desirable to manage the ongoing fire extinguisher inspection process. Schedules, forms and lists will have to be established for, among other types of items, fire drills; safety rounds; safety and security monitoring of the EC; ongoing testing, inspections and maintenance; fire wall inspections; fire alarm and fire protection systems; devices and equipment; fire extinguishers; fire and

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

smoke dampers; eyewash stations; and emergency power, medical gas and vacuum and other systems. Health care facilities also need to manage the inspections of all “previous” building management plan (BMP) components such as smoke and corridor walls, fire smoke and corridor doors, exit signs, egress lights, waste and linen chutes, grease-producing devices and means of egress Labelling is expected for hazardous materials and waste, utility system controls to facilitate partial or complete emergency shutdowns, medical gas and vacuum system valves, and both permanent and temporary signage. Maps, if used, also should be labelled. Utility maintenance documentation must be accessible during an accreditation survey. This includes documentation generated both internally and by outside services. The organisation must have processes and contract provisions to obtain, store and access all such documentation during equipment failures and unannounced surveys. The decision process for the types of maintenance (i.e., preventive, predictive, reliability-centred, corrective or metered) to be performed on all new equipment should also be documented and available. Similar requirements apply to maintenance documentation for other types of equipment, including equipment that is serviced by internal biomedical engineering departments as well as external service organisations.

Operationally Ready Hospitals when at a state of readiness remain subject to regulatory inspection any time after they are transformed from a construction site to operational health service entities. Health facilities management professionals should be cognisant of their responsibilities in this regard to ensure ongoing post-occupancy operational compliance. References: John Wieser, Nina Lowe, Mary O’ Driscoll, – Anatomy of the Hospital Project Life Cycle – OHA Planning Conference October 8, 2009

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

PRODUCT NEWS

Product News Schneider Electric partners with the Australian Centre for Health Innovation

to understand further what the operational issues and end-user pain-points are across healthcare facilities and how these can be addressed to improve efficiency and productivity.

Long-term partnership to enable knowledge sharing and innovation in the Healthcare sector Schneider Electric, the global specialist in energy management has reached a partnership agreement with the Australian Centre for Health Innovation (CHI) in Melbourne to enable hands-on interaction with its latest intelligent, integrated healthcare technologies.

“We are very excited about this opportunity and what the joint collaboration will mean for enabling healthcare innovation across Australia,” says Glen Scott, National Healthcare Manager, Schneider Electric. “Through this partnership, over 6,500 yearly visitors to the centre such as clinicians, health administrators and clinical IT professionals will be able to interact first hand with Schneider Electric’s innovative healthcare infrastructure solution at a direct interface within the clinical environment.”

The centre will display Schneider Electric’s EcoStruxure integrated architecture, showcasing its capabilities across the sector, validating Schneider Electric’s value propositions within the Australian healthcare environment. Schneider Electric’s partnership with CHI will enable the organisation

BECS Technology pH & chlorine controllers from the USA are available in Australia Tim Batt Water Solutions now offers the well proven and extremely reliable BECS Technology range of BECSys controllers from the USA, formerly known as ‘Strantrols’. The BECSys controller range features the simplest possible operation, with an easy to use keypad and reliable, low maintenance pH, ORP, free chlorine and temperature probes in windowed flowcells. Sample flowswitch protection is a standard feature. These controllers are ideal for use in Hospital hydrotherapy pools, cold water or warm water systems to ensure consistent disinfection is maintained with stable chemical levels. All models have

for the organisation. “We are delighted to welcome Schneider Electric on board at CHI, and we look forward to working with the organisation in an ongoing partnership, which we see as benefiting both parties as well as future healthcare developments in Australia,” said Susan Harrison, General Manger, CHI.

H I Through the valued partnership, Schneider Electric is able to market test its newly introduced, leading solutions and demonstrate its expertise in the healthcare sector. It will also enable Schneider Electric to focus on the key areas of improving healthcare productivity and efficiencies. The partnership cements Schneider Electric’s offer in Australia’s healthcare market which is a core sector

the ability to be connected to a PC for simple remote control and monitoring via Windows 8 compatible ‘BECSys for Windows’ PC software. This enables simple download and graphing of readings and event data, as well as remote operation and more advanced programming of the systems.

BECSys controllers give a powered relay or dry contact control output to any type or make of chemical feeders and provide proportional control for accurate dosing, along with full alarm and failsafe protection. Tim Batt Water Solutions offers the Pulsar dry chlorine briquette system, suited for hydrotherapy pools with plantrooms that are too difficult to access with liquid chlorine delivery and storage. The Pulsar system is widely used and provides

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

The Australian Centre for Health Innovation facilitates testing and simulation for service improvements adopted in patient care, health administration and safety across Australia and New Zealand healthcare facilities. Its expertise in simulated education, experiential learning and solution design delivers great outcomes to the toughest health challenges across the country. Schneider Electric’s solutions are already being showcased and functional at CHI.

excellent water quality and ease of operation.

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TBWS are also distributors for the premium Siemens UV disinfection and chloramine removal systems, Siemens Ezetrol and Depolox Pool controllers and Pulsatron electromagnetic dosing pumps. Installation and full service support are provided nationwide by a network of approved installers.

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TIM BATT WATER SOLUTIONS can be contacted on ph 0438-889268 or timtbws@bigpond.com

A E PRODUCT NEWS

LEGIONELLA CONTROL APPLICATION CASE STUDY

Industry: Hospital/Aged Care Facility Period: Feb 2011 – current

Site Issue: Continual HIGH LEGIONELLA BACTERIAL LOAD in the production and distribution systems of domestic hot water.

The system in place: UV (Ultra Violet) systems: The existing system operating was not effective in eliminating continued high counts. The warm water recirculating system was regularly maintained and serviced, however the results continued well above an acceptable range. Even though the system was dosed with Chlorine, as per the required procedure for a high count excursion, the problem still persisted. Finally the UV system was reviewed and a fourth UV lamp was added to the system. Legionella and plate counts continued even with this upgrade.

Teamwork pays dividends

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INTEGRA INTERVENES It was at this stage that Integra was introduced to the site. The installation of a chlorine dioxide, known as Twin-Oxide, chemical dosing system was recommended.

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Bentrol are gaining a reputation in the industry for their keen and professional attitude, with a fervent client focus.

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• Digital proportional chemical dosing pump

“I have enjoyed working with Chris and the team at Bentrol over many successful projects within our organisation. Their attitude towards service delivery and the “can do” approach that all of their employees possess makes it a pleasure to have them on our project team.” – Adam Hardinge, Construction Manager, Bendigo HealthNew Hospital Project Contact us: sales@bentrol.com.au, www.bentrol.com.au 03 5448 3288

This system can cater for varying loads as it doses the TwinOxide chemical proportional to water usage.

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This is a relatively inexpensive installation/capital investment in comparison to traditional/UV methods.

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DOSING EQUIPMENT Consists of; • A pulse out-put capable water meter

Two years ago, the same team headed by Chris Frankel formed the new company, Bentrol; in order to not only continue support for their previous employer, Bendigo Health, but also for other hospitals and commercial entities such as: CFA Headquarters, in Melbourne, La Trobe University in Bendigo, Hospitals at Horsham and Shepparton.

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• Injection lance

IMPLEMENTATION STRATEGY The application of a sanitising system with continuous dosing directly on the domestic hot water was required due to the fluctuating trend of Legionella load in the water. After a thorough inspection of the warm water recirculating system, a dosing range of 0.2 and 0.3 ppm was applied in order to ensure the continuous residual of TwinOxide. The facility is made up of several buildings, each with independent wards and the dosing range is maintained at 02.-0.3ppm.

At Bentrol, the team of engineers and technicians work closely together to ensure that they provide the best solution for their clients. The Bentrol story starts more than 10 years ago when the team was formed with visionary foresight by Engineering managers at a major regional hospital to undertake an overhaul of the HVAC power and control systems and in the process, provide significant energy saving.

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• Chemical dosing tank

The TwinOxide solution comes in two parts (PART A and PART B) which in a raw form are nonhazardous and can be easily stored and/or transported safely.

The application of this system since 2011 has successfully held the hospitals results within target range and the hospital authority has since extended this service to other hospitals within their portfolio.

To see an example of this product and system, visit Integra at the IHEA Healthcare Facility Management Conference, 9-11 October, Sheraton on the Park.

Infection Control & Hand Hygiene is Key

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Legionella and infection control issues are challenging factors that affect the healthcare sector particularly for engineers and facility managers. Galvin Engineering’s healthcare product range has been specifically designed following extensive research into the needs of healthcare managers, design professionals, and clinicians. The CliniLever Hospital and Aged Care tap range and CliniMix Thermostatic Mixing Valves ranges combines innovation with practical attention to detail giving engineers and facility managers the total plumbing solution for the delivery of safe and controlled water delivery. Galvin Engineering leads the market with products that enable healthcare managers to provide a safer environment for staff, patients and the general public.

The Healthcare sector is highly regulated, and Galvin Engineering has responded to this challenge by investing heavily in a programme of continuous product development, compliance and innovation.

This programme means that Galvin Engineering’s healthcare products meet and in many cases exceed the national standards covering hospital and aged care and mental healthcare institutions. From approvals with ASNZS: 4032.1, and NSW Health Department Approval of Thermostatic Mixing Valves, specifying professionals can be sure that Galvin Engineering’s healthcare product range exceeds national standards.

To learn more about the extensive range of healthcare taps and thermostatic mixing valves visit www.galvinengineering.com.au or contact the team on 1300 514 074.

THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2013

PRODUCT NEWS Sparkling, healthy and effortless without breaking the budget Health Safety and legislation Hospital pools and spa pools have a number of requirements that must be met, vary from state to state Public Health departments. This aims to improve public health by controlling recreational water illnesses and infectious diseases. There are different risk categories for every pool and spa, meaning that different water management plans and equipment is required to meet or exceed compliance. To understand which category group individual hospital’s swimming pool or spa pool meets is based on assessment of risk for each pool or spa. Assessment review includes parameters such as bather load and likely use, ability of the pool operating system to respond to water quality changes, primary disinfectant used, water test method used, manual water testing frequency and logged, level of likely environmental contamination, the climate, health and age of bathers, if the pool or spa is heated and the location of the facility if indoors or out as a minimum. Additionally pool fencing, signage, Australian Standards, Work Health and Safety legislation are referenced providing operators with a road map to maintain compliance. Notification/registration per pool are a requirement in some states.

Energy & Time Saving Off-set costs by utilising new energy efficient equipment. Whilst saving overall energy costs daily this equipment can also be measured through reducing the hospital’s carbon footprint of emissions. Begin with eight star energy efficient pump. Additionally operator time saving and work efficiency can be as simple as introducing, a Robotic Cleaner. The latest technology these cleaners operate totally independent of the filtration system. Once placed in the pool/ spa simply leave it to map its way around the pool floor and climbing walls. On return the 4WD Robotic Cleaner has scrubbed the entire pool and the easy to clean filters have collected debris down to 2 microns.

For further information visit: www.poolwerx.com.au

Foster’s Services is a West Australian based electrical and communications company specialising in the healthcare industry for the last decade working across many sites. Foster’s Services specialise in Body and Cardiac protected electrical areas. We can design, service, install and commission these areas to suit your facilities. Yearly testing and compliance of Body and Cardiac protected areas is easily achieved with our experienced team and customer management system. We provide electrical services across public and private hospitals, medical clinics, consult rooms and nursing home facilities including a 24 hour on call service to our customers. Other services we can provide for you health care facilities include: Electrical, structured cabling, fibre optics, thermo graphic imaging and High Voltage switching. Foster’s Services works with your facility to ensure that Australian standards are met or exceeded. We understand the importance to keep your site compliant and will work with you to achieve this in a professional and safe manner. For further information visit: www.fosters.net.au

Summit Matsu Chillers manufactures Australias most reliable chillers for critical process and machinery cooling. Part of Air Change, with combined factory and office area of nearly 4000m2, Summit Matsu Chillers quality process spans Sales, Production, and Service for longer chiller life. Customers in 2012/13 have included Wollongong Hospital, Fortescue Metals Group (Cloudbreak and Kings Valley), Millennium Minerals, Dyno Nobel, Tech Plas Extrusions and Hewlett Packard.

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Pool Maintenance Having standard operating procedures detailing regular and preventive maintenance programs extends the life of the equipment, lessens the cost in chemicals and reduces water usage. This ensures continued operating of the pool. Coupled with regulative maintenance of on-site log books all adds to a smooth trouble free pool or spa. A trained operator can result in substantial cost savings.

FOSTER’S SERVICES

Summit Matsu Chillers

Medical customers in the past have included Wollongong Day Surgery, Perth Radiation Oncology, Goulburn Base Hospital, Prince of Wales Hospital, and Mater Hospital.

Summit Matsu Chillers is a licensed electrical contractor with full knowledge of all Australian standards.

Summit Matsu Chillers is also a licensed refrigeration and air conditioning contractor and can offer whole of life chiller service from commissioning to preventative maintenance either directly or through its national contractor network ensuring reliable performance for the life of any chiller unit. For more information call 1300 CHILLERS (1300 244 553) or visit www.matsu.com.au

Austco is a worldwide provider of IP Nurse Call Solutions with over 27 years experience in the healthcare market, across 8000+ sites, in over 60 countries. With products designed to comply with global healthcare standards, the Austco team is fully committed to providing quality products and global support services to all our clients. Our flexibility to integrate into various technologies enables a healthcare facility to continue to drive efficiencies to achieve an overall quality healthcare solution.

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Established in 1985, Austco Communications is recognised as a world leader in the highly specialised field of electronic communications for the healthcare and secure accommodation environments. Austco’s Corporate head office is based in Melbourne and the international manufacturing facility is located in Perth, Western Australia and has established an Australia-wide network of highly trained Resellers as well as dedicated offices in New Zealand, Canada, USA, UK and Asia. With representation in Europe, Middle East and Latin America, Austco provides call systems to facilities throughout the world.

Specifically, we design and manufacture a family of dedicated microprocessor Emergency Call Management Systems for the hospital recognised globally for its innovative approach.

For further information visit: www.austco.com

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T N I Looking E CforI La top L A solution? F A

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Delivering innovative valve solutions

Zetco’s T4 Top-Entry ball valve for medical gases has all the required features:

 Full bore entry design  Top allows service and maintenance of seals

Phone 1300 659 639 Email enquiries@zetco.com.au www.zetco.com.au

body is cleaned  Internal and ready for installation

 Sizes 15mm to 50mm 91