ENGINEERING

Engineering in Health Care Facility Design

Understanding an important role

BY BRENT WAVRA, PE – MECHANICAL ENGINEER

To help understand engineering in health care, it’s helpful to compare it to the human body. Each health care facility has a skeletal system which is the building structure, internal organs are like the mechanical / plumbing system, nervous system is comparable to the electrical / IT systems, and think of the skin as the walls that hold it all inside. The consulting engineer’s responsibility is to ensure that all systems are designed to allow the building to become alive after construction is complete. Just like every person is unique, each health care facility is unique. Strong communication skills are the key to success when it comes to designing a new building or remodeling an existing health care space.

Engineering in Health Care

We start with the end in mind–each health care facility operates with its own idiosyncrasies that make up its unique nature and culture. As consulting engineers, it’s imperative we understand from the start what the stakeholders’ needs are when it comes to the day-to-day operations of their facility. We must also discuss the facility’s operational goals, energy use, care team function and overall patient satisfaction objectives.

Input from facility staff and stakeholders is valuable information as we start to lay out our system designs. Architects provide detailed renderings of different areas of the building, e.g., layouts of patient rooms, operating rooms and lobbies based on heavy input from the stakeholder group. Mechanical, electrical and plumbing (MEP) consulting engineers need similar guidance. For example, we need to know how the medical gases will be arranged on the headwall within a patient room, the preferred location of a med gas alarm panel, the optimal temperature setting in an operating room, emergency power needs for outlets, preferred equipment manufacturers–all of which make the workspace tailored to the needs of staff for an efficient and functional environment.

The character of a health care space is typically determined by what you see and physically identify within the facility. Elements like window locations, wall color, artwork and space layout tend to be the items that influence perception of the facility by patients and health care workers. However, nearly 40% of the building is located behind the walls, above the ceiling or in hidden utility spaces that have a higher impact on care, but have a less tangible impact on a person’s perception of the facility. The mechanical and electrical systems determine temperature, humidity, air

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filtration, infection control, water, medical gases, lighting, power, data, nurse call, way finding and other items. Many things play a significant role within the space without the users directly identifying them. The bricks and mortar of a facility are static and visibly noticeable; however, the mechanical and electrical systems are alive within the building, if unseen.

It is never too early to start understanding the MEP needs of a health care facility with the finished project in mind. Many MEP systems drive overall design decisions. For starters, the engineers need to understand and coordinate space requirements for MEP systems, because most of the equipment is located above the ceiling and determines the height of the building. In some hospitals, separate floors route the MEP infrastructure throughout the building. Another significant consideration is incorporating serviceability of the MEP infrastructure and the cost of doing so. It’s important to remember each square inch of building costs money and additional space to service equipment does not turn revenue like a patient room. Taking time to coordinate with facility personnel, the architectural design team and the construction manager will find the best solution and the right price, both of which are crucial for a successful project.

Secondly, MEP systems and supporting infrastructure are expensive. The cost for MEP generally accounts for nearly 40% of the cost of construction. Knowing the MEP needs of the facility early on helps the entire project

team and owner understand the financial implications associated with these systems. For example, MEP systems can range from $50-$150 per square foot. Applying that to a 400,000 square feet replacement hospital means the systems cost can range from $30 million to $70 million. Having an early understanding of MEP systems needs for present and future use helps provide clarity into the project budget from the start and avoids the need to cut costs later. Communication during design is the path to success. The cost for MEP generally accounts for nearly 40% Engineers role on the Design Team of the cost of construction. As health care engineers, we know the value we can provide from the start and our work with our architectural partners is a part of the process. Our goal is to be an integral part of the design team and bring a thorough understanding of how early design decisions can affect the engineering systems’ design and implementation for the project. Understanding the goals, timeline and budget of a construction project is valuable information used early on during design of a new project. Each of these components is used to determine the correct type of heating, ventilation and air conditioning (HVAC) to coordinate with these criteria. For example, if the goal of the project is to provide an energy-efficient mechanical Engineering in Health Care Facility Design to page 244

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3Engineering in Health Care Facility Design from page 23

system, then a geothermal system might be considered. Coordinating a location of the geothermal well field with the civil engineer is a hurdle to work through, but possible when both parties are brought to the table early on. Another example is a project’s compressed construction timeline, which determines manufacturing lead times of mechanical and electrical equipment and may drive the system selection.

There are hundreds of scenarios like these, which if discussed at the beginning of the project with a consulting engineer, keeps the design process moving forward from the beginning. If not, there is the possibility of going backward to redesign parts of the project to accommodate the correct MEP system that fits the building needs. This can result in slowing down the design process and jeopardizing the construction schedule.

Knowing the best way to communicate our designs and the effects of design decisions to people outside of the design and construction community is an important part of our job. As consulting engineers, we prepare our design on 2D set plan drawings for the constructors to construct. We also work with the design team within 3D models to better understand how our designs affect the overall project outcome. Working within this 3D modeling medium is called Building Information Modeling (BIM). BIM has changed how we

can work with the architectural design team, other consulting engineers and specialty consultants. We can effectively see how our design works within the space before it’s built, saving time and money during the construction process. Another benefit to 3D technology use within our industry is the ability to use virtual reality so an owner can see their project before it’s built. In the past, owners would try to imagine how Net Zero means providing renewable energy solutions along with onsite energy generation. a project would aesthetically look, feel and function based on the 2D design drawings. Now, they can “walk through” a project before it’s built and make design decisions based on what they are seeing in real time versus getting through construction and wishing they had made different decisions. From an engineering perspective, the locations of wall switches, lights, sinks, medical gas outlets or light levels are now easily seen and understood. This is useful for medical staff involved in the design process–they can see how they could work within the space and suggest changes to help improve their ability to provide better care. Not all mechanical and electrical systems are as obvious as lighting, domestic water, and room temperature, but they are the backbone within a health care facility that make the building function. Systems like central utility plant–heating, air conditioning, steam, and power–along with terminal devices like air handling units for creature comfort and filtration for infection control. These unseen systems play a signification role for

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the life of the building and need to be discussed early during the design process. They don’t have the awe factor like other building components such as a grand lobby or granite counters, but they provide a safe, healthy, and functional environment for all. To provide the best solution, bringing in an MEP engineer in at the beginning of the process allows time for the MEP systems to be appropriately incorporated into the building. The required footprint of the MEP systems takes valuable real estate within the facility and the sooner this is accounted for the better it is hidden within the building and allows the beauty of the building shine through.

Benefits of Engineering in Health Care – Inside and Out of Your Building

Engineers contribute to many benefits within the facility for your patients and staff. We contribute to a healthy and safe working environment, as well as clean and healing spaces for your patients. We can be resources for your facilities teams to keep your building functioning at its best. But we also look beyond the ways we can provide benefit inside the building.

As good stewards of the earth, the MEP industry is working towards more energy efficiency solutions when designing buildings–including health care facilities. The term Net Zero is a buzzword right now but is often misunderstood. Net Zero means providing renewable energy solutions along with onsite energy generation to offset what the facility is consuming. Net Zero does not mean having zero energy consumption or being off the grid.

The first step in working toward Net Zero is reducing the building energy consumption to limit the cost of renewable and onsite generation. Many health care facilities have energy/water conservation goals outlined in their long term Environmental, Social, and Governance (ESG) plan, which sets conservation goals of the health care provider. Health care facilities have one of the highest Energy Usage Indexes (EUI) of commercial spaces. The high EUI is due to 24/7 operation and high concentration of outside air and power consuming devices, but there is still an opportunity for energy saving design solutions.

Systems that provide the greatest energy reduction include optimizing the chilled water plant used for air conditioning, using airside energy recovery, fine-tuning the HVAC control sequencing, implementing daylight harvesting and collecting rainwater for irrigation. But energy conservation does not sit solely on the shoulders of the MEP engineers. For example, the orientation of the building on the site in relation to the sun, the number and locations of windows and wall and roof insulation values all go into quantity of energy the building uses.

In Conclusion

Finally, the MEP systems are a critical element in the operations of a health care facility. These unseen systems play a significant role for the life of the building and need to be considered at the very beginning of and throughout the design process. It is important to discuss and set energy conservation goals as early as possible so the entire design team can find effective solutions.

Brent Wavra, PE is a Mechanical Engineer and Director of Business Development for Obernel Engineering.

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3Accessing Mental Health Care from page 21

Similar to how younger generations have helped to normalize conversations about mental health, their outward advocacy and openness have made talking about mental health more of a strength than a weakness, as it used to be seen. This has been helped by social media and online apps designed to build resiliency, diagnose and even treat mental illnesses. We can all become advocates and speak out against stigma. This will help support all of those around us and provide a safe conversation if we need support ourselves.

Helping Your Patients

All health care systems and providers have a responsibility to respond to mental health needs of patients. This requires more training in mental health, including identification of symptoms, crisis management, and providing basic care to those experiencing symptoms. This also means awareness of the reasons people don’t access care when they need it. It is estimated that nearly 50%-70% of primary care visits involve a mental health concern, but it is rarely discovered. Some providers hesitate to hear the story because connecting their patients with mental health resources can be difficult. This is a systemic issue–our network of mental health resources is not broken, because it has not yet been built. When we don’t listen to the patient’s story, we erode engagement in care and we miss things.

It is estimated that nearly 70% of people with a chronic health condition also struggle with their mental health. These conditions are almost always treated separately, and the referral follow-through to a mental health provider is about 50%. This drives up costs and decreases the quality of care. For example, one common comorbidity is diabetes and depression. If treated separately, the costs of care could be three times more than if they were treated at the same time. Diet, exercise and insulin are all critical factors for both conditions, but absence of the other’s treatment plan results in different independent recommendations. Failure to effectively care for diabetes can exacerbate depressive symptoms, and increased depression can lead to worse follow-through on medical recommendations for diabetes. We need to treat them together. Local integrated health care models have shown to increase patient follow-through by 52%. In some cases, co-located therapists were able to care for 250% more patients in the integrated setting than in a stand-alone clinic by themselves.

Minnesota offers a Psychiatric Assistance Line (PAL) for any health care provider seeking consultation on a specific case. This free on-demand service is managed by clinical social workers and staffed by board-certified psychiatrists. This helps alleviate numerous access barriers and helps primary care providers treat psychiatric conditions directly in their own care setting.

While this list is not exhaustive or detailed, it helps to summarize the main factors that prevent many from getting mental health treatment when they need it. We can help connect people with service by advocating for parity and fairness in access and by talking about the signs and prevalence of mental illness. This will help to increase awareness and the likelihood that someone will get help when struggling.

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3Care Transitions from page 19

rather than the default mindset of “that other provider has taken over at this point.” True collaboration keeps the patient as the core focus at every step and in the mind of every provider.

Documentation is not paperwork but an extension of care. Imagine what the U.S. healthcare experience would look like if providers thought about transition documentation as the book version of the movie— the whole story, just in written form. If you value the readers and decision-makers who reference the EMR and other handoff or discharge documentation as customers who need the whole story, how might patient outcomes be improved for the better?

A balance of listening, speaking and written instructions is needed. For a provider to insist that “I’m more of a talker than a writer” or “I answered all the patient’s questions, so I didn’t think it necessary to outline a full transition plan” or “They were given written instructions—that’s all they should need” is simply not adequate. Ensuring clarity in communication requires a thoughtful balance of listening, speaking and written instructions.

Mindset matters. Perhaps the most common phrase heard during a hospital morbidity and mortality review or during a deposition or trial in the wake of a malpractice lawsuit is “I didn’t think that” or “I assumed that.” Our perspectives, frames of reference, assumptions and mindsets matter when it comes to patient care—sometimes to a life-and-death degree.

Stitching together a fragmented health care environment begins with you. Health care providers and administrators face a daunting daily task— serving patients optimally in a system that often fails when it comes to interoperability. So while it’s true that broader ecosystems are sometimes at fault for individual cases of patient harm, the stitching together of process gaps, dysfunctional teams, or siloed systems happens one provider and one leader at a time. It begins with you.

Conclusion

Every day in the United States, millions of care transitions take place for patients in hospital, out-patient and continuing-care settings, most without major incidents but all with inherent risk for poor outcomes. In this article, we have identified key factors that can contribute to poor care transitions and ways to mitigate these factors. We also recognize that relationship building, partnerships, and effective communication belong to all stakeholders— health care professionals, patients and families, as well as communities.

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This article is excerpted from a report published by Coverys—Care Transitions: Through the Lens of Malpractice Claims. You can access the full report online from the Coverys Knowledge Center at Coverys.com/KnowledgeCenter or link to: https://www.coverys.com/knowledge-center/a-dose-of-insight-care-transitions

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3Improving Early Detection and Intervention from page 10

research areas span the developmental topics like nutrition, stress, obesity, infection, toxins, addiction, autism and schizophrenia. Because their laboratories are not located on the MIDB campus, their interaction with clinical researchers and clinicians is facilitated by the Translational Neuroscience Core. This core is responsible for putting together research teams of pre-clinical and clinical researchers around the developmental topics noted above. This powerful interdisciplinary approach allows us to pinpoint the important biological factors that underlie the diagnosis and treatment of many neurodevelopmental disorders. Providing biological plausibility and proof is key to sharpening our approaches to treating neurodevelopmental disorders. It is key because we can be more specific in our therapies and the timing of those therapies when we know the biology. Many of our M Health Fairview clinicians at the MIDB are also researchers and educators at the U of M . They’re immersed in these discoveries, and we hope the Translational Neuroscience Core will even further expand collaboration across university departments and into medical care.

What are some of the longer term goals for the MIDB?

The most important goals are to shorten the timeline from discovery to intervention and to engage the community in brain development activities. As Dr. Fair has pointed out, the discovery to intervention process can take as long as 17 years, and that is simply unacceptable for our rapidly growing and developing children. We believe that the new efficiency of putting the researchers, educators, policy makers and clinicians in a single setting will facilitate speeding up that timeline. Ultimately, we want to learn from every patient’s experience to make our approaches better for the next patient who comes along. From a community perspective, engaging underrepresented individuals in neuroscience and helping those patients with difficulty in accessing consistent, effective and individualized neurobehavioral services are main focal points. Building these programs will take time, but will pay off in the long run because ultimately prevention of mental health problems through early detection and intervention far outweighs the cost of diagnosing and treating them later in life.

What would you like physicians in Minnesota to know about how they can become involved with the MIDB?

It is estimated that up to 50% of physician visits for children involve discussion, diagnosis and treatment of behavioral issues. When primary care physicians need additional consultation, there are multiple subspecialties which assess and potentially treat neurodevelopmental issues: pediatric neurologists, neuropsychologists, developmental pediatricians and child and adolescent psychiatrists. Yet fundamentally all of these subspecialists are assessing brain health and function. The MIDB brings all of these disciplines together in a single setting with a concise approach so that each child can potentially be evaluated by team members from all of these disciplines. From that intake, an individualized plan can be crafted to address a child’s needs, fueled by new knowledge and innovative approaches. Long term we hope to be a learning resource for physicians in Minnesota so they can leverage the knowledge generated by and tested in the MIDB in their own practices.

Michael Georgieff, MD, is the co-director of Masonic Institute for the Developing Brain and a professor at the U of M Medical School and College of Education and Human Development. He is a neonatologist at M Health Fairview Masonic Children’s Hospital.

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THE INDEPENDENT MEDICAL BUSINESS JOURNAL Volume XXXII, No. 05

Physician/employer direct contracting

Exploring new potential

BY MICK HANNAFIN

With the continuing escalation of health care costs, large and midsized selfinsured employers are once again looking for an edge to manage their medical plan costs and their bottom line. They understand that they are ultimately funding health care as they pay for their population’s claims.

Many of these employers have employed the same overarching set of strategies: shop for a new carrier that is willing to lower the administrative costs or underprice the risk,

Physician/employer direct contracting to page 124 CAR T-cell therapy

Modifying cells to fight cancer

BY VERONIKA BACHANOVA, MD, PHD

University of Minnesota Health is now among the few selected centers in the nation to offer two new immunotherapy drugs for the treatment of diffuse large B-cell lymphoma. Both drugs—Yescarta and Kymriah—are part of an emerging class of treatments, called CAR T-cell therapies, that harness the power of a patient’s own immune system to eliminate cancer cells.

CAR T-cell therapy involves drawing blood from patients and separating out the T cells. Using a disarmed virus, the patient’s own T cells are genetically engineered to produce chimeric antigen receptors, or CARs, that allow them to recognize and attach to a specific protein, or antigen, on tumor cells. This process takes place in a laboratory and takes about 14 days. After receiving the modification, the engineered CAR-T cells are infused into the patient, where they recognize and attack cancer cells. Kymriah received initial FDA approval in 2017 for the treatment of pediatric acute lymphoblastic leukemia.

CAR T-cell therapy to page 144

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