By Charles Zube

Vice President/Medical

www.SpawMaxwell.com

Although the familiar dictum “First, do no harm” is often wrongly associated with the Hippocratic Oath (many scholars believe the phrase first appeared in Hippocrates’ treatise Epidemics), it is a worthy premise from which to begin any renovation project. An uncertain economy may have slowed the start of some planned medical construction projects; however, demand for medical services will remain strong for the foreseeable future. Continuous use of systems and medical equipment, and an aging population, means that planning for capital improvement projects in the medical community will continue.

Sound preconstruction planning – budget pricing, schedule, and constructability reviews of architectural drawings – is invaluable in the early stages of a construction project, and can help reassure stakeholders responsible for the fiscal health of the enterprise. Understanding how a general contractor plans to approach a project – before selecting a contractor and starting construction – is an important part in the planning and qualification process. 

Construction is messy business. Disruption of routines can be mitigated, but often cannot be avoided completely: Whether it’s construction from the ground up, which can be disruptive if schedule and budget go awry, or the renovation of an OR inside a functional operating suite (an extreme example).The difference in these two construction scenarios is zero tolerance for unplanned disruption inside an operational medical facility during a renovation– and rightly so.

Too much is at stake to expect anything short of flawless delivery with minimal disruption during a medical facility renovation. Maintaining negligible impact on delivery of patient care is essential. Regular communication between the construction team, design professionals, facilities management, key physicians and staff is the most basic threshold to ensure a successful project. Still, the need for detailed communication once a project is underway cannot be overstated. Even with extensive planning and an experienced construction crew, the possibility exists for human error, material, product or systems malfunction. That reality is magnified when it means patient care may be comprised.

Preconstruction risk assessment

Perhaps a more appropriate adage when preparing for a renovation is “Understand the risks, and plan accordingly.” An infection control preconstruction risk assessment is a mandatory first step. The AIA publication, Guidelines for Design and Construction of Hospital and Healthcare Facilities 2001 provides a comprehensive overview of risk assessment. Some construction best practices include:

• Construct an anteroom of fire-rated material around the construction zone to contain dust and reduce noise
• Identify the types of construction activities planned – cutting, sawing, drilling or demolition; estimate the amount of debris, dust and particulate matter generated
• Place dust caps on heat detectors at the start of each work day and ensure removal at the end of each shift
• Erect temporary barriers around the construction zone; paint and tape the joints between barriers to help contain dust
• Create and maintain negative air pressure in work zones and maintain proper HEPA filters (high-efficiency particulate air) in negative air machines
• Install negative air flow indicators within temporary barriers and monitor effectiveness of negative air systems
• Seal off and block return air vents inside the construction zone
• Relocate patients away from work zones; divert pedestrian traffic
• Provide designated entrances, corridors, and elevators for crews
• Clean work zones daily; wet-wipe tools and tool carts before leaving work area; use “tacky mats” to capture dust from shoes

The challenges for the general contractor in a medical setting during concurrent occupancy are significant: Managing the needs of the medical staff and the demands of facility personnel while juggling the absolutes of an invasive construction project. It can be a complicated dance. The key is stealthy execution. Going unnoticed is the highest measure of success for a medical interior construction crew.

 

 

Vibration and Noise Control

Controlling vibration is never an absolute. Insulation around the construction zone can help. Conducting loud and vibration causing activities like saw cutting, hammer drilling or concrete demolition during the day to avoid patient sleep disruption helps as well. Finally, when disruptive activity is unavoidable, mandating a schedule of 20 minutes on and 20 minutes off provides additional relief to affected patients and staff. 

Service Disruption

Understanding the building being renovated, knowing the location and source of critical systems – oxygen, medical gas, chilled water, hot water, power, and the alarm system – must be carefully documented prior to starting construction. A service disruption should be planned well in advance with a minimum 72-hour notice provided to facility personnel, physicians and staff. 

Mold Prevention

Typically, mold is not an issue during an interior renovation. However, any existing mold if found, must be remediated before commencing work. Once interior construction begins, maintaining “building standard” or controlled air at all times during construction is necessary. It is also necessary to maintain the relationship between positive air pressures v. negative air pressures around the construction zone in accordance with the preconstruction risk assessment. Crews must ensure that negative air and positive air machines, and the appropriate HEPA filters are in place and functioning properly.

Hot Work

Before starting any spark-generating activity – welding, acetylene torch demo, or grinding – the construction team must ensure there are no impairments to the fire suppression system or fire alarms. After completion of any “hot work,” the risk assessment plan should require an individual to be stationed in the area where the work was conducted for at least 2 hours with a fire extinguisher nearby to ensure no re-ignition of fire. When a ceiling grid is removed during renovation, all sprinkler heads must be turned toward the ceiling to minimize the distance between the sprinkler sensor and the floor deck above to ensure early activation of the sprinkler system in the event of heat build up due to fire. 

Commissioning, Inspections and Closeout

Whatever medical related technology was installed or taken offline during a renovation must be made operational as soon as possible. The intent is to avoid protracted disruption of service in the interest of public health, and to minimize the negative impact on revenue to the facility. Both the facility personnel and user groups should attend inspections to help answer any questions relating to the operation of the facility. Closing out a job means assembling all the paperwork associated with a project – warranties, liens, operation and maintenance manuals, test results, and as-built drawings. Ask your general contractor if they have a dedicated close-out department and their typical duration for closing out a job. As-built drawings that show actual location of ductwork and other building elements versus the original plans should be maintained as construction progresses creating a “living document.” As-built drawings are turned over to the owner at the completion of the project. 

 

Construction inside an occupied medical facility requires crews to have elevated skill and a sharpened awareness of their surroundings. Unplanned disruption of service or systems during a medical facility renovation carries potentially life threatening consequences. Adopting the layman’s understanding of the Hippocratic Oath that of “doing no harm” should be the guiding principle for construction and design professionals undertaking a medical renovation. It starts with a thorough preconstruction risk assessment.  

 

Charles Zube spent 10 years as a facilities director for a major trauma center in the Houston area before joining www.SpawMaxwell.com as a project manager. He was named an officer in the company in 2004.  SpawMaxwell has delivered 30 million square feet of medical and commercial construction since the company was founded in 1998.