Healthcare sector engineers are looking to improved patient outcomes as the next measure of their efforts to design smarter facilities.
Previous Engineering Dimensions treatments of the links between engineering and healthcare have focused primarily on such areas as digitalized medical records, biomedical engineering advances, fine-tuning and precision enhancements of surgical devices, and the process system applications to patient scheduling and wait-time reduction.
Each of these themes in their own way emphasize the vital interplay between engineering and medicine and the importance of technology in helping medical practitioners better respond to patients’ needs.
Expanding on the mutual benefits of engineering and medicine, the concept of the “engineered hospital” becomes especially relevant given the number of constraints involved in healthcare design, and the policy considerations in controlling spiralling costs of healthcare in Ontario. And, while elected leaders talk of the value of evidence-based policy making, the need for engineers in the healthcare sector to buttress their designs and recommendations with hard evidence grows even more acute.
Advancing the symbiotic relationship between engineering and the healthcare sector is recent research showing that improved design and patient environments lead to better health outcomes in hospital settings. The notion has been emphasized in part by the 400-page Canadian Standards Association (CSA) Z8000 Health Care Facilities Standard. Launched in 2011, the CSA Z8000 is considered the first comprehensive standard for the planning and design of hospitals and other healthcare facilities. In general, CSA health-related standards are reviewed and updated every five to 10 years.
CSA Z8000 also incorporates several existing CSA technical standards for healthcare facilities, such as standards for HVAC, lighting and commissioning. CSA Z8000, however, is the first document to be all-encompassing, and its influence on engineers in the healthcare sector has been profound.
“Before now, there was no common national standard for the design and construction of hospitals and other healthcare facilities,” the CSA notes. “Each healthcare facility building project undertaken in Canada has relied on the knowledge and resources available to the architects and consultants engaged. This standard sets out requirements and addresses concerns specific to healthcare facilities, beyond what is contained in building codes and guidelines. The new standard provides a cohesive, nationally recognized baseline for healthcare facility design and construction/renovation.”
Engineers and other professionals working with the standard focus not only on safety and efficiency but also on the impacts of the physical environment and even ambient air quality on the healthcare outcome. Using available knowledge in evidence-based design as outlined in the standard, engineers and other players in the healthcare sector can establish an environment that promotes positive health outcomes, quicker recovery, a reduction in medical errors and the recruitment and retention of valued caregivers.
Gordon Burrill, P.Eng. (New Brunswick), was vice chair of the technical subcommittee that helped produce the Z8000 regulation.
The current president of Teegor Consulting in Fredericton, NB, Burrill has more than 30 years’ experience in the healthcare engineering field. Teegor is best described as healthcare engineering codes and standards specialists. “We typically act as a technical resource for hospital engineering departments at all stages of a hospital’s life cycle, from planning to design to construction to operations and maintenance,” Burrill told Engineering Dimensions.
IMPACT OF DESIGN
Burrill cites the Z8000 standard as a clear manifestation of the profession’s expanding influence in the wider healthcare sector. While engineering input in the past concentrated primarily on oversight of hospital equipment, operations and processes, it has come to take on greater prominence in facilities management, refurbishing existing infrastructure and smart integrated design and construction of new hospital buildings.
“I believe there is a great opportunity to engineer away some of the risks associated with healthcare,” Burrill says. “I have worked with a couple of healthcare organizations that have brought in the industrial engineering expertise to look at process management and, as a result of doing that, have improved healthcare delivery efficiencies and significantly reduced patient risk elements. The human factors elements, too, are getting more attention where, through analysis, we’ve been able to eliminate some of the ‘hot spots’ in buildings—places where clinical people bump elbows in the operating room, for instance. By engineering the layout of the operating room, you start to eliminate some of those collision points. And every collision point and every crossover between clean and dirty supplies [for example] is a risk spot for healthcare delivery.”
Another engineer with an intense healthcare focus, and who helped prepare the CSA Z8000 standard, is Michael Keen, P.Eng., executive director, chief planning and redevelopment officer at St. Michael’s Hospital in Toronto, Ontario.
St. Michael’s is about to amalgamate its operations with two other Toronto-area institutions, St. Joseph’s Health Centre and Providence Health Care, which will bring more facility redevelopment work under Keen’s auspices.
Keen was chair of the 33-person national committee that formulated the new standard. He says one of the standard’s most noteworthy features is its requirement for single-patient rooms, especially to curb acquired infections for patients coming in for treatment.
Single-patient rooms have been found to help cut down on the spread of infections in hospitals, which is a common problem, Keen says. According to CSA, 220,000 people every year acquire infections while visiting or staying in healthcare facilities in Canada.
“The standard we have put in place is an attempt to provide a better environment for patient care to happen [and] to enhance efficiency, safety and other physical environment issues but there certainly is a demand out there in the industry for evidence when it comes to these standards,” Keen told Engineering Dimensions. “One of the things that came in when we did Z8000 was to move to 100 per cent single-patient room for in-patients, and that is a real departure. Many of our facilities in Canada maybe averaged 20 per cent single-patient rooms. We did a research project last year at CSA that we are just in the process of finalizing. What we are finding is that the design aspect has had a huge impact on reducing the number of hospital acquired infections.”
Keen is pleased to note that hospital acquired infections seem to be on the decline since the Z8000 standard was released. “There is another area that I think we need to continue to work as engineers in healthcare and that’s in doing studies on the impact of design, and process design for that matter, on the outcomes for patients,” Keen adds. “We can study what works and what doesn’t work and how can we translate what does work into our future designs.”
Much of Keen’s healthcare-related engineering work involves older hospital infrastructure that often must be retrofitted to comply with modernized standards. It’s similar in a way to the work of engineer Lisa Nagel, P.Eng., manager, infrastructure renewal at the University Health Network (UHN), an organization overseeing the operations for four Toronto area teaching hospitals.
“The renewal we deal with involves reviewing the building systems, electrical, mechanical and the entire building envelope,” says Nagel.
Nagel, who worked for 16 years in healthcare design at HH Angus in Toronto prior to joining the UHN, says a key work area for healthcare engineers today involves planning to determine when infrastructure will reach the end of its useful service life and require replacement in order to continue to serve patients’ needs into the future.
Clearly, an overwhelming constraint for healthcare engineers dealing with infrastructure renewal is the cost factor, Nagel adds. “You often make a lot of sacrifices to get a new building erected but once a building is up people will celebrate having their new facilities,” she says. “But our department must also make sure we’re not neglecting our existing facilities to ensure they are getting the proper care, maintenance and cost-effective utilization they deserve.”
As some engineers ply their trade in getting more value out of existing healthcare infrastructure, others are devoting their mindset to maximizing the benefits of new builds. And while the entire field of healthcare engineering isn’t new, it has become an increasingly important business development area for consulting engineers.
As one example, Kevin Cassidy, P.Eng., national lead of healthcare engineering at WSP Engineering in Markham, Ontario, has been involved in several hospital new build and redevelopment projects over his career.
Cassidy has observed a trend towards involving more ambulatory and community based healthcare out of hospitals and into the home and community. In order to support this, he says, hospital building infrastructure is going to need to accommodate new communication technologies and allow patients to access information from their homes and local clinics. Properly engineered systems will enable this communication between the home and the hospital.
A related trend is that hospitals in Canada are getting smarter by integrating building systems with clinical systems. This allows the buildings to react automatically to the needs of the staff and patients and seamlessly transfer information between departments and caregivers.
“I think as much as we like to think that engineering is very logical—step A, step B—when we are dealing with hospitals there are still some basic steps to follow but you get the whole emotional, people side of things, which isn’t as predictable as some of the other steps,” Cassidy says.
Cassidy is especially excited about the engineering enhancements to the new Humber River Hospital in Toronto, and the yet-to-be complete Mackenzie Vaughan Hospital northwest of Toronto. Humber River Hospital is celebrated as North America’s first fully digital hospital, while Mackenzie Vaughan, scheduled to open in 2020, will be the first Canadian hospital to feature fully integrated smart technology systems and medical devices to enable maximum information exchange.
“Maybe I’m biased but I can’t think of a [hospital] building type where the social impact of the decisions we make is more apparent,” Cassidy says. “There is a big sense of accomplishment when you see the positive social impact you can make and, at the same time, you are cognizant that these are some of the most vulnerable people in our society who really depend on what we are doing.”
Cassidy says with increased concerns about the costs of healthcare and the innovative ways to secure funding for its new infrastructure, the influence of engineers at the early design stage is taking on even greater importance. “I think what you are seeing now is a trend where people are very cognizant of the things that we can do to lower healthcare costs, improve outcomes, have people stay home instead of coming into the hospital, and what we are doing behind the walls has just as much impact,” he says. “Now what we are doing is gathering the data proving that this approach is working, and we are seeing some of the research science and the engineering overlap.”
Cassidy anticipates ongoing and intensified data collection by engineers to improve the physical environment in healthcare institutions. “What we would really like to see is global scale data collection,” Cassidy explains. “Let’s start collecting all the data. We’re at a point where we have sensors and ways to measure light output, temperature in your room, air changes, etc. Now we are becoming sophisticated enough that we can gather that data, look at it and work with our hospitals to see, for example, if a change of two degrees in a room means recovery from a flu will be this much faster, and we are starting to pull that data.”
A HOLISTIC APPROACH
Given the emphasis on engineers working in healthcare settings, it’s no surprise that an organization aimed at fostering the development of non-MD healthcare professionals would have special insights into the healthcare engineering niche.
Roger Holliss, P.Eng., director of engineering at St. Mary’s General Hospital in Kitchener, Ontario, is vice president of the Canadian Healthcare Engineering Society’s (CHES) board of directors.
“CHES’s mission is to assist its membership in being able to provide the best healthcare environment possible, both from an ongoing/operational perspective and from a design and proactive perspective,” Holliss says.
Holliss’s interest in healthcare engineering and questions about the engineered hospital naturally flow from his work at St. Mary’s and because of his long-time involvement with CHES.
“I initially joined CHES as a means of developing my healthcare network and to speed up my learning curve relative to learning the particulars of running, maintaining and building hospitals instead of warehouses and printing plants,” Holliss says. “Over the years, I got to be pretty good at engineering within healthcare to the point where I could start helping others as much as I got help from other members. These last few years, I find myself being able to substantially help other hospital facility managers in improving the quality of their healthcare facilities to the point where, both provincially and nationally, people would approach me to consider running for CHES offices.”
While holding the P.Eng. licence isn’t a membership requirement of CHES, Holliss believes it’s important for the organization to support all members whose work approximates that of professional engineers, especially as it can lead to better health outcomes.
But, as an engineer with extensive experience in healthcare settings, Holliss is still eager to promote the ongoing engineering contributions to hospital design and healthcare. At the same time, Holliss believes Ontario’s healthcare system needs to be more proactive and assertive in bringing the best engineering it has to offer to its operations.
“I think there are lots of contributors to this,” Holliss says. “The systems and equipment within these infrastructure systems have constantly become more technically complicated over the years. As such, the skill set required by facility managers to optimize hospitals has evolved beyond being just the subject matter expert on certain systems or equipment to more of a holistic systems mentality. Therefore, the historic succession-planning strategy of internally promoting the boiler person or plumber to a facility management role isn’t as appropriate today as previously.”
Holliss adds that when this internal promotion strategy is coupled with inadequate training—both generic and building management—it puts the new facility managers in a tough position to be successful. “Senior hospital managers are starting to see now that they need to augment their tradespersons’ skill set with formally educated people for the purposes of efficiently managing these very complex facilities,” Holliss says.
Whatever the credentials and experience of professionals in healthcare settings, there’s little doubt today that engineers remain poised for new inroads. In some ways, improved health outcomes has become a challenging, difficult-to-satisfy constraint that will continue to inspire engineers grappling with the many complexities of designing, building and maintaining today’s health institutions.
Says Gordon Burrill of Teegor: “We are delivering a service and we are performing a function, and there are efficiencies and inefficiencies in however you do that. When I look at the Canadian healthcare system, people will say there is not enough money in healthcare, but we have lots of money in the Canadian healthcare system and our challenge is that we are not getting it channeled in the most effective manner.”
Despite political and policy differences that impact the allotment of resources to healthcare facilities across Canada, engineers within the sector are optimistic they are up to the battle.