Ageing of hospital estate assets is a growing concern for many European countries, and indeed in any country in which care has been largely provided in buildings that are at least 30 years’ old. Against this backdrop, with physical constraints, a lack of decanting facilities, shortage of funding, and socio-political choices, refurbishment of existing buildings is often seen as more viable than building new healthcare facilities. Since January 2020, the COVID-19 pandemic has piled further pressure on the healthcare system, including built assets and their operability. In this context, the refurbishment of the Surgical Block at San Paolo Hospital in Puglia, Italy, provides some useful real-world strategies to mitigate uncertainty and risk in project design and construction – from stakeholder consultation and needs, to final commissioning and operation.
Healthcare delivery in Italy
In Italy, 82% of the existing hospital building stock was built before 1990, and 58% before 1970. In Liguria and Marche 59% and 47% of the provinces’ hospital buildings respectively pre-date 1946.1 Puglia is no different – 31% of its hospital building stock was built pre-1946; 12% between 1947 and 1969; 46% between 1970 and 1989, and just 11% constructed post-1990.1
The healthcare system in Puglia is mainly public, with some private providers contributing to the delivery of care together alongside the public system. Delivery of healthcare services is via 45 Health & Social Care (H&SC) Districts, gathered together in six Local Health Authorities (LHAs). Facilities include 31 Integrated Community Care Centres; five second-level hospitals (with an average 825 beds), 16 first-level hospitals (average of 299 beds), and 12 basic hospitals (average 127 beds). The aforementioned public hospitals include two hospital Trusts and two research hospitals.
The San Paolo Hospital
The San Paolo Hospital in Bari opened to the public in the 1990s. The monoblock hospital has a linear design with a single corridor layout, eight floors, and two underground floors. It is structured in three separate towers, aligned in parallel, and joined together on the shortest side, to form one single building block. There is also a lower block, with two above-ground and two subterranean floors – housing the hospital’s Emergency Department and Surgical Block, with a dedicated route and accesses.
Over the years, regular maintenance and partial refurbishments have ensured that the hospital remains compliant with regulations, as well as able to accommodate new clinical practices and technologies, variations in the population catchment, and new patient needs.
Technological advancement and changes across the healthcare arena have continuously put pressure on the existing built assets in which care is delivered, meaning that maintenance and refurbishment play a key role, alongside new design. The definition of maintenance implies two processes: retaining to avoid failure, and restoring post-failure.2 The definition of refurbishment, meanwhile brings up six dimensions: social, ecological, economic, cultural, architectural, and technical.3 Both definitions encompass the underlying concept of sustainability, which has acquired particular significance during the recent pandemic – with the resulting social, economic, and political
instability at international level. In this context, strategies to mitigate uncertainty and risk in project design and construction of hospital buildings acquire pivotal importance – even more so when we are taking about the refurbishment of specific spaces, such as operating theatre blocks, that are essential to the continuity of service delivery.
Identifying strategies to mitigate uncertainty
In this article I will set out to identify some useful strategies to mitigate uncertainty and risk which were deployed during the refurbishment – during the COVID-19 pandemic – of a surgical block, at a time when, with considerable pressures on the healthcare system, keeping the hospital in question fully operational became critical. This paper describes the refurbishment project, from design to construction and delivery. I will look at the key issues in the old surgical block, and the local clinical needs, which jointly informed the design of the new layout, which was discussed with the hospital’s clinical staff to ensure that the outcome would not only meet legal requirements, but also support the operational processes. Also examined will be the key strategies we followed to deliver the construction on time and on budget, which have been critical to the project’s success, and indeed to the operation of the entire hospital at a very challenging time.
Uncertainty and risk in construction projects
Project management success depends on how complex the project requirements are, and how precisely they are met: time, cost, and quality, are the fundamental criteria against which it is commonly measured. A construction project is a dynamic project, in which the three criteria above can, and are likely to, be subject to change. Accurate information and high levels of detail are two elements that can support change without putting at risk successful project completion. Nonetheless, unexpected events can result in deviations from the project delivery plan at any time: the further into the delivery these happen, the greater the impact on the project. Uncertainty and risk are extremely different aspects to deal with, and acknowledging the difference can become key, especially in complex construction projects, in which complexity is often associated with the project size, cost, time, or constraints.
Uncertainty is a result of factors that are both internal and external to the organisation. Human factors rely on levels of experience, and the expertise of the stakeholders involved.4
The more complex the project, the more people involved
The more complex a project is, the more stakeholders will be involved, increasing the degree of uncertainty. Non-human factors are linked to the environment in which the project is being developed, including, for example, the supply of construction materials and transport. Meanwhile, risk is defined as a combination of the probability that an accidental phenomenon will occur in any given period, and how serious a potential impact this would have. Risk can be identified; uncertainty cannot. Within a specific context, one can identify the key risks by determining the likely impact of a specific event on a specific project aspect. Risk management techniques include re-structuring the risk (i.e. breaking down the issue in order to put in place an appropriate response); transferring the risk (i.e. transferring it to another party at a cost), and sharing the risk (i.e. sharing the gains, and insuring and retaining the risk).
When assessing uncertainty, the impact on the project is far more difficult to identify. The likelihood that an uncertain event may occur, and the effect of this event, are extremely difficult to predict and measure, leading to the definition of unpredictable uncertainty. In some circumstances, it may be more sensible to simply accept uncertainty as a component of the project, and adapt the way one might respond.
Key issues in the old Surgical Block
The Surgical Block is located on the first floor of the San Paolo Hospital, and is connected to two separate parts of the hospital, both parallel to it. Neither the block’s eight operating theatres or the annexe support spaces have been refurbished since the hospital’s opening – for a number of reasons, key being maintaining the continuity of services. The original layout of the space, during the years, has been under evaluation and monitoring, as new procedures and new technologies emerged. The construction and finishing materials dated back to the 1980s, and needed upgrading to meet statutory requirements.
The hospital Trust applied for funding to carry out a complete refurbishment of the Surgical Block, and also the implementation of the Haemodynamic Service on the same floor, with the ambition to create a safe, efficient, and effective service delivery to address increased local needs (i.e. catchment area), but also capable of meeting future needs.
Project design
The main purpose of the refurbishment project was to achieve fire safety compliance with new statutory requirements, but the project also provided the opportunity to redesign the layout of the Haemodynamic Service, with the addition of the new Lounge Room to complement the service and increase patient comfort, safety, and privacy.
In the Surgical Block and all the annexe spaces, the project included:
the installation of fire compartmentation between different departments and different floors;
fitting of new fire-resistant doors on the escape routes, with removal of existing glazed doors;
the expansion of the automatic fixed fire detection and alarm systems;
the expansion of the alarm and sound diffusion system;
the design of a new medical gas system;
new electrical systems, with new LED lighting;
installation of new air-conditioning systems – including AHUs, distribution ducts, and terminal units, and
the fitting of new windows compliant with fire and safety regulation.
The project also involved the refurbishment of two operating theatres, and a new design for the the Lounge Room to enhance the hospital’s Haemodynamic Service – previously delivered in single room – and to improve the patient journey, from the waiting area, through to preparation, therapy, and discharge.
A quiet area to relax in
The new Lounge Room layout was designed to offer the patients a quiet area to relax in before and after medical treatment, with space for rest, reading, and internet access, etc. This facility is strategically located, to allow direct access to the two new operating theatres for haemodynamic treatments once patients have entered the Surgical Block.
The design strategy addressed the physical elements (e.g. different ceiling heights in the operating theatres 1, 2, 3, and 4, and theatres 5, 6, 7, and 8, levelled out via the installation of a false ceiling at The design strategy addressed the physical elements (e.g. different ceiling heights in the operating theatres 1, 2, 3, and 4, and theatres 5, 6, 7, and 8, levelled out via the installation of a false ceiling at
The final layout delivered a complete, fully equipped new Surgical Block, with six operating theatres, plus ancillary support spaces, and a new fully equipped Haemodynamic Service area, with two dedicated haemodynamic theatres, and associated ancillary facilities.
The Surgical Block incorporates the rooms listed below, and shown in the floorplan in Figure 1.
1 Operating theatre 1
2 Theatre 2.
3 Theatre 3.
4 Theatre 4.
5 Theatre 5.
6 Theatre 6.
7 Haemodynamic room 1.
8 Haemodynamic room 2.
9 Sluice room.
10 Washing & sterilisation room.
11 Clean utility.
12 Dirty utility
13 Storage.
14 Scrub room.
15 Induction room.
16 Neonatal area.
17 Medical equipment room.
18 Control room.
19 Disposable material storage room.
20 ‘Recovery’ cubicles.
21 Orthopaedics sterile supply material.
22 Orthopaedics equipment.
23 Orthopaedics ‘prep’ room.
24 Physicians’ relaxation room.
25 Physicians’ room.
26 Monitoring & control room.
27 Staff relaxation room.
28 Sterile utility room.
29 Female staff changing room – filter area.
30 Male staff changing room – filter area.
31 Stretcher change area – filter area.
32 Head nurse’s room.
33 Staff changing room.
34 Physicians’ room, and
35 Physician on call. The Lounge Room houses the rooms listed below, and shown on the floorplan.
A Front and control desk.
B Anamnesis room.
C Male patient changing room.
D Female patient changing room.
E Patients’ cubicles.
F Reading area, and
G Internet area
Project design and construction management were undertaken by Nikolaos Pantzartzis. Delivered via a traditional procurement scheme, the project included the installation of new furniture and equipment throughout the Surgical Block Lounge Room. The design phase lasted 90 days, as planned.
Delivery strategy, uncertainties, and risks
The initial delivery plan took into account the need to keep both the Surgical Block and the Haemodynamic Service operational throughout construction. Phasing was the key strategy to ensure that the works could be carried out safely while the operating theatres and the haemodynamic service were in operation.
The delivery plan for the Surgical Block works initially comprised four phases, each interspersed by a two-month period to re-locate the construction site, and the temporary installation of the external cranes needed to undertake the external works and move the construction material, as described below. The first phase included the temporary set-up of theatres 7 and 8 (i.e. the operating rooms dedicated to the haemodynamic service), to allow the service to be delivered without interruption. The second phase entailed undertaking the works on theatres 1, 2, 3, and 4, the third phase involved the work on theatres 5, 6, 7, and 8, and the fourth and final phase saw the construction, fitting out, and furnishing, of the new Lounge Room.
Impact of COVID on construction
The construction commenced in April 2019, as planned, but in December 2019 early news about COVID-19 started to be disseminated, and in January 2020 the outbreak arrived in Europe, including in Italy. At that time, the situation required extreme caution, both in terms of how hospitals were operated (e.g. maintaining separate routes for COVID-19 and nonCOVID-19 patients), and as regards hospital capacity (with, for example, a heightened need for hospital beds and ICU beds for COVID patients)
Having already begun, the works needed to be carried out and completed as quickly as possible. The likelihood of an unforeseen incident – with a potentially significant impact occurring – increased; the Surgical Block was working at only half capacity, with only four operating theatres in use due to the works having started. The planned phasing remained in place, but given the special circumstances, work had to be put on hold at some of the most challenging times, both to allow healthcare professionals to use all the available space, and so as not to put the construction staff at risk. The delivery schedule was adjusted, and the four phases reduced to two, with one already ongoing.
Revised construction schedule
The first phase of the revised delivery plan included the work in theatres 5, 6, 7, and 8. Once these were completed, the area was tested and operated at full capacity, while the works commenced in the adjacent area. The second phase included the work in theatres 1, 2, 3, and 4, together with the work to build the Lounge Room. In alignment with this, the work on the Haemodynamic Services facilities in theatres 7 and 8 were divided into two phases. A new angiography system was installed and activated in theatre 8, with treatment undertaken in the old area. Treatment activity then commenced in the new theatre, with its new equipment, while the existing angiography system was removed from the old area, installed, and made operational, in theatre 7; the result being no interruption to delivery of haemodynamic services to patients.
Uncertainty over both internal and external factors which might affect the construction project also had an impact. As COVID-19 spread, a number of construction workers contracted the virus outside the project site, mostly from family members, resulting in a lack of personnel on site – a situation which required constant monitoring and scaling up to deliver the works on schedule. Another issue – which the Project manager had started to anticipate after the initial months of the pandemic – was the supply of construction materials and raw materials, with staff shortages significantly impacting the supply chain, including production and transport. To avoid excessive delays, the materials and equipment were ordered at the earliest opportunity, and alternatives for material and equipment suppliers discussed and proposed to the stakeholders, with preference given to local suppliers. The adjustments and variations that were considered acceptable to the Trust and the stakeholders were put in place during the periods of non-activity, to make sure that all the materials and equipment arrived in time for the next stage.
The construction works, and the installation of the new equipment, were completed in June this year, as scheduled in the revised delivery plan, with the entire project finished in 18 months.
Conclusions
Maintenance and refurbishment play a key role when new-build is not a viable option. The refurbishment of the Surgical Block at San Paolo Hospital provided the opportunity both to address local health needs, and to plan for the future, with the new Haemodynamic Service facilities and the new Lounge Room offering a safer and more efficient experience to patients and their relatives. Work included the refurbishment of the wallcoverings, floor coverings, and installation of new false ceilings – all aligned with specific clinical needs and relevant regulations, together with the new M&E technology and systems (i.e. air-conditioning, electrical, lighting, water, fire, alarm, and medical gases) for each specific functional space. The project included the installation of new doors and windows, and of equipment for the new theatres and the haemodynamic operating rooms, as well as the design of the new Lounge Room.
The COVID-19 outbreak and the resulting emergency conditions in its aftermath had a substantial impact on the project’s construction and operational phases. The original construction phasing had to be adjusted to maintain the continuity of clinical services. Notwithstanding the calculation of potential risks, this project demonstrated how unpredictable uncertainty can still be managed
A proactive strategy and on-site project management
Having a proactive strategy, and efficient monitoring in place throughout the works’ entire duration, in tandem with an emergency response strategy, and expert on-site project management, were all key to the successful delivery of such a complex project – on an operational hospital site, during a time of emergency, during which all the stakeholders, site workers, and hospital staff, needed to be kept continuously informed on any small variation that could potentially impact their activities.
This paper highlights six real-world strategies to mitigate uncertainty and risk in project design and construction:
1. Knowing and understanding the external environment and context within which the project is to be delivered (i.e. the local context, and the potential elements of disruption);
2. Being fully cognisant of the internal working environment (i.e. as regards all the project stakeholders and the various on-site personnel);
3. Phasing the works with an element of slippage built in to allow for unexpected events;
4. Identifying critical times at which specific activities are to be carried out;
5. Anticipating the need for additional resources (i.e. workforce, construction materials, and technological changes), and
6. Timely monitoring of the works and the staff involved at specific times (i.e. performing reviews at identified critical times).
While this article does not aim to be exhaustive and definitive – given that the project described is strictly linked to the physical context and conditions in which the designer and co-designers had to operate, but it does highlight how it is possible to mitigate uncertainty and risk in project design and construction throughout a project – from identifying stakeholder needs, to delivery of the completed facility.
Efthimia Pantzartzis
Efthimia Pantzartzis, MArch, MSc, PhD, is a healthcare architect and consultant. She has worked for over 15 years in the public sector on healthcare refurbishment projects in Italy, and on EPSRC and DH England-funded projects on hospital productivity and efficiency, healthcare infrastructure value, critical infrastructure risk, dementia-friendly health and social care environments, and A&E departments. She has been senior expert at ASSET Puglia, and Assessment manager at AReSS Puglia. She is currently a consultant for the EIB on Health Facilities Investments Guidelines, and for the Conformity Assessment Body of ASSET Puglia on healthcare facility projects.
She has served as Adjunct lecturer on Product Design and Elements of BIM at the Politecnico di Bari (Italy), and as a Visiting Academic at Loughborough University since 2018. She holds an MSc in Planning Buildings for Health, and a PhD on Resilience and Sustainability of Health and Social Care Infrastructures. She has authored HBN 08-02: Dementia-friendly health and social care environments, 10 double blind peer-reviewed journal papers, 11 project reports, one book chapter, and over 20 national and international conference papers. She is a registered member of the National Board of Architects of Bari, and of the Italian Society of Architecture and Engineering for Healthcare (SIAIS).
Nikolaos Pantzartzis
Nikolaos Pantzartzis, MEng, is a mechanical engineer born in Corfù, with over 36 years’ experience in public complex schemes, who has worked in both the public and private sectors – on residential, commercial, hospitality, and exhibition projects, including the IBM Travelling Exhibition (1982-1984) with Renzo Piano of Ove Arup & Partners. His expertise includes project design, construction, and maintenance of technological systems of healthcare facilities; energy management, design, energy certification and consumption optimisation; refurbishment and restructuring of buildings and services; project and construction management, and fire protection system design.
He has previously worked in Greece, but since 1993 has mainly worked in Puglia in the public healthcare public sector, on several acute hospital project designs and refurbishments. Between 1997 and 2002, he provided consultancy services to AUSL BA/4 as senior expert.
Schemes he has worked on include: the restructuring of the hospital building, and refurbishment of the operating block, delivery block, haemodynamic unit, and intensive care unit, at San Paolo Hospital in Bari; the design of a dialysis and nephrology unit at a new provincial Hub, and the design of a reproductive medicine department at the Di Venere Hospital in Bari.
References
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5 ISO 31000:2018 – Risk Management: guidelines, and ISO Guide 73:2009 – Risk Management: vocabulary