NBS BUILDING SCIENCE SERIES

U.S. DEPARTMENT OF COMMERCE / National Bureau of Standards

Health and Medical Facilities

Design

M

-TAAO. 54

IS 14
NATIONAL BUREAU OF STANDARDS

The National Bureau of Standards' was established by an act of Congress March 3, 1901. The Bureau's overall goal is to strengthen and advance the Nation's science and technology

and facilitate their effective application for public benefit. To this end, the Bureau conducts

research and provides: (1) a basis for the Nation's physical measurement system, (2) scientific and technological services for industry and government, (3) a technical basis for equity in trade, and (4) technical services to promote public safety. The Bureau consists of the Institute for Basic Standards, the Institute for Materials Research, the Institute for Applied Technology,

the Institute for Computer Sciences and Technology, and the Office for Information Programs.

THE INSTITUTE FOR BASIC STANDARDS provides the central basis within the United

States of a complete and consistent system of physical measurement; coordinates that system

with measurement systems of other nations; and furnishes essential services leading to accurate and uniform physical measurements throughout the Nation's scientific community, industry, and commerce. The Institute consists of a Center for Radiation Research, an Office of Measurement Services and the following divisions: Applied Mathematics — Electricity — Mechanics — Heat — Optical Physics — Nuclear

Sciences " — Applied Radiation ^ — Quantum Electronics ' — Electromagnetics ' — Time

and Frequency ' — Laboratory Astrophysics ^ — Cryogenics ^. THE INSTITUTE FOR MATERIALS RESEARCH conducts materials research leading to improved methods of measurement, standards, and data on the properties of well-characterized

materials needed by industry, commerce, educational institutions, and Government; provides

advisory and research services to other Government agencies; and develops, produces, and

distributes standard reference materials. The Institute consists of the Office of Standard Reference Materials and the following divisions: Analytical Chemistry — Polymers — Metallurgy — Inorganic Materials — Reactor

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Environment * — Technical Evaluation and Application * — Fire Technology.

THE INSTITUTE FOR COMPUTER SCIENCES AND TECHNOLOGY conducts research and provides technical services designed to aid Government agencies in improving cost effec- tiveness in the conduct of their programs through the selection, acquisition, and effective

utilization of automatic data processing equipment; and serves as the principal focus within

the executive branch for the development of Federal standards for automatic data processing

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divisions: Computer Services — Systems and Software — Computer Systems Engineering — Information Technology.

THE OFFICE FOR INFORMATION PROGRAMS promotes optimum dissemination and

accessibility of scientific information generated within NBS and other agencies of the Federal Government; promotes the development of the National Standard Reference Data System and

a system of information analysis centers dealing with the broader aspects of the National Measurement System; provides appropriate services to ensure that the NBS staff has optimimi

accessibility to the scientific information of the world. The OflSce consists of the following

organizational units: Office of Standard Reference Data — Office of Information Activities — Office of Technical

Publications — Library — Office of International Relations.

1 Headquarters and Laboratories at Gaithersburg, Washington, D.C. 20234.

" Part of the Center for Radiation Research.

3 Located at Boulder, Colorado 80302. Part of the Center for Building Technology.

Maryland, unless otherwise noted; mailing address
Health and Medical Facilities Design

Proceedings of the

First Federal Agency Workshop

Held at the

National Bureau of Standards

Gaithersburg, Maryland

December 5, 1972

Edited by

Robert J. Kapsch

Institute for Applied Technology

National Bureau of Standards

Washington, D.C. 20234

U.S. DEPARTMENT OF COMMERCE, Frederick B. Dent, Secretary

NATIONAL BUREAU OF STANDARDS, Richard W. Roberts, Director

Issued July 1974
Library of Congress Cataloging in Publication Data

Federal Agency Workshop on Health and Medical Facilities Design, 1st, National Bureau of Standards, 1972. Health and Medical Facilities Design.

(National Bureau of Standards Building Science Series, 54) Supt. of Docs. No.: C13.29/2:54.

1. Health facilities —Design and construction—Congresses. I. Kapsch, Robert J., ed. H. United States. National Bureau of Standards. IH. Title. IV. Series: United States. National Bureau of Standards. Building Science Series, 54. [DNLM: 1. Facility design and construction—Congresses. 2. Health facility planning—Congresses. 3. Hospital design and construction

Congresses. W3FE253 1972p/WX140 F293 1972p]

TA435.U58 No. 54 [RA967] 690\08s [725'.5] 74-10561

National Bureau of Standards Building Science Series 54

Nat. Bur. Stand. (U.S.), Bldg. Sci. Ser. 54, 87 pages (July 1974)

CODEN: BSSNBV

U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON: 1974

sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402

(Order by SD Catalog No. CI 29/2:54). Price $1.25.
FOREWORD

Dr

.

James R. Wright

for Building Technology, I AT Bureau of Standards

Director, Center

National

Department of Commerce

Building research at the National Bureau of Standards is over fifty years old. However,

it has only been recently that we have been sponsoring monthly meetings for Federal

agencies interested in the planning, design and construction of buildings. This Federal

Agency Workshop, on Health and Medical Facilities Design, is an example of these meetings

held by the Center. In addition to our Federal Agency Workshop Program, the Center for

Building Technology seeks to disseminate building research results from other countries

through formal agreements, translations, and exchange of technical teams. In addition,

the Center sponsors interdisciplinary research efforts from our 220 professionals and

40 disciplines for other Federal agencies on topics such as housing, energy conservation,

office buildings, physical security and many others. It is through these efforts that

we at the Center hope to aid professionals engaged in providing improved housing and

places of work for Americans through building research and the effective dissemination

of research resul ts

.

iii
PREFACE

Samuel Kramer

Chief, Office of Federal Building Technology

Center for Building Technology, lAT National Bureau of Standards

Department of Commerce

The Program of Federal Agency Workshops in building research was established at the

National Bureau of Standards by a request from the Office of Management and Budget

over four years ago. This program was established to coordinate the construction

activities of the various Federal agencies, to provide a means for the reporting of recent building research results and to provide a forum for the Federal agencies to discuss their common building related problems. By all measures, this program has

proved to be a success. This publication contains the proceedings of one of our workshops, on Health and Medical Facilities Design. The presentations made in this

workshop were primarily given by representatives of other Federal agencies, such as Department of Defense, Veterans' Administration, Department of Health, Education and

Welfare. The scope of these agencies research into the planning, design and

construction of health and medical facilities is certainly extensive. Based on the

comments that we received after this workshop, it was decided that the Center for

Building Technology would have a regular workshop program in the area of medical

facility planning, design and construction.

iv
ABSTRACT

The Federal agencies have a large involvement in the area of Medical Facility

Design; both in directly operated Federal facilities and indirectly through grant, loan

and funding programs. Because of the impact of technology and because of the very

large cost for new medical facilities; the last few years there has been the rise of

a field best described as medical facility research. These papers, presented at a National Bureau of Standards Federal Agency Workshop, describe the latest medical

facility research efforts by the Federal agencies including the Department of Defense,

Department of Health, Education and Welfare, the Veterans' Administration and the

National Bureau of Standards.

Keywords : Architecture; design; hospital design; medical facilities; medical facility

research.

V

NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Gaithersburg , Md. (Issued July 1 974)

INTRODUCTION

Robert J . Kapsch

Assistant Chief, Architectural Research Section

Center for Building Technology, lAT National Bureau of Standards

Department of Commerce

The Federal agencies have a large involvement in the area of Medical Facilities

Design. Over 400 hospitals in the United States, representing over 160,000 hospital

beds, are directly operated by Federal agencies, including the Department of Health,

Education and Welfare (HEW), the Department of Defense (DoD) , and the Veterans'

Administration (VA). Besides hospitals and other medical care facilities which are directly operated. Federal agencies effect the design of non-Federal hospitals and other

medical care facilities through programs such as the Hill-Burton Program of HEW for

construction loans, medical facility standards and technical advice; Federal Housing

Administrations' (HUD) program for loan guarantees, Medi care/Medi cai d reimbursement

for health care providers; National Institute of Health's grants for medical research

facilities and others.

In the last ten yea'^z medical facilities have become much more complex. Sophisticated equipment such as electronic physiological monitors, automated laboratory

testing devices have been introduced into many American hospitals. There has also been

an increasing use of electronic data processing techniques and automated material

handl i ng systems . Along with the increased level of complexity has come an increase in cost in con- structing new medical facilities. Once new medical facilities, although never inexpensive, cost relatively modest amounts of money to plan, design and construct. Now however,

under the impact of the application of technology, there are several new medical facilities either under design or construction whose costs exceed $100 million.

Because of the impact of technology on medical facilities and because of the cost

of new medical facilities in the last few years we have seen the rise of a field of

study that can be best described as medical facility research. In the past, medical

facility planners and designers have engaged in some limited research efforts. However,

these efforts usually engaged no more than one, two or three professionals. The medical

facility research projects that have been undertaken in the last few years are of a much

different nature. These efforts have been of a large scale, some taking years to complete.

vii
Whereas the traditional medical facility research has been accomplished by one or two individuals within the organization responsible for designing the facility, these new medical facility research efforts typically call for the assistance of several external

organizations. Finally, where traditional medical facility research has used one and

perhaps two disciplines, these new medical facility research efforts have been truly

mu 1 1 i d i s c i pi i na ry

.

The rise of medical facility research is not a phenomenon unique to the United

States. Rather, it is a worldwide trend in those countries which are facing the impact

of technology in medical facilities and the great increase in cost of medical facilities.

For example, the Ministry of Health in Great Britain for the last few years has been

sponsoring Project HARNESS, a medical facility research project to optimize the design

and construction of new hospitals. Sweden is another country engaged in such a program.

The Institute for the Planning and Rationalization of Health Services and Social Welfare

(SPRI) was established in 1968 to conduct these investigations. One of SPRI's primary

missions has been to improve the planning, design and construction of medical facilities

in Sweden through research.

The papers given in this workshop illustrate the growth of medical facility research

in the United States in the last few years. Mr. Sigmund Gerber describes a major Department of Defense development effort to generate a New Generation of Military Hospitals,

by incorporating the latest available technology. John Reese of the Hill-Burton Program,

a program which has been actively engaged in medical facility research for many years,

presents the latest standards for medical facilities developed by that organization.

Howard Fogarty and Bruce Keane describe the extensive use by the VA of computers to aid

in the planning and programming of new medical facilities. In the area of building

systems, John Cook describes the VA's extensive medical facility research project, "The

VA Hospital Building System." Donald Boyle and Joseph Russo discuss HEW's use of new management concepts for the planning, design and construction of new medical facilities.

Finally, Robert Wehrli describes the National Bureau of Standards' own work in this area, an evaluation methodology for nursing units.

These papers summarize efforts which represent millions of dollars spent on medical

facility research by the Federal agencies. It is through efforts such as these that we hope to improve the comfort and care of the patient, enhance the effectiveness and

efficiency of the medical staff, and provide medical facilities at a cost the Nation

can afford.

viii
TABLE OF CONTENTS

FOREWORD

James R. Wright, Director, Center for Building Technology, NBS i PREFACE

Samuel Kramer, Chief, Office of Federal Building Technology, NBS ii INTRODUCTION

Robert J. Kapsch, Assistant Chief, Architectural Research Section, NBS .... iii TABLE OF CONTENTS v ABSTRACT vi

The New Generation Hospital

Sigmund I. Gerber, Department of Defense ' 1

Rationale for Change--The Hill-Burton Program

John W. Reese, Department of Health, Education and Welfare 13

Introduction: Application of Advanced Technologies to Hospital Design in the Veterans' Administration

Robert L. Rosenberry, Veterans' Administration 23

Space Planning and Equipment Requ i rements -Appl i cati on of Advanced Technologies

to Hospital Design in the Veterans' Administration

Howard J. Fogarty, Veterans' Administration 25

Use of the Computer in Planning Hos pi t a 1 s - Appl i ca t i on of Advanced Technologies

to Hospital Design in the Veterans' Administration

Bruce D. Keane, Veterans' Administration 27

Veterans' Administration Hospital Building System-Application of Advanced

Technologies to Hospital Design in the Veterans' Administration

John C. Cook, Veterans' Administration 31

Introduction: Current Issues in Health Care Delivery

Donald D. Boyle, Department of Health, Education and Welfare 45

Application: Current Issues in Health Care Facilities Design

Joseph D. Russo, Department of Health Education and Welfare 49

An Evaluation Methodology for Hospital Nursing Units

Robert Wehrli, Department of Commerce . 63

ix

NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Gai thersburg , Md. (Issued July 1 974 )

The New Generation Hospital

Sigmund I. Gerber

Director of Construction Standards and Design

Office of the Secretary of Defense

Department of Defense

ABSTRACT The Department of Defense has some 240 major hospitals and 460 dispensaries

serving over 10 million people and employing about one quarter of a million medical

and allied personnel. In 1968, a new project was initiated; A New Generation of

Military Hospitals. The objectives of this project were to provide a more efficient

health care delivery system through the extensive use of technology. The project

consisted of two phases; Phase I was the systems analysis study of military and

civilian hospitals and Phase II was the design and construction of a test bed military

hospital. A number of recommendations resulted from Phase I, including use of a completely computerized hospital, convenience food system, light care nursing, out- patient surgery and others. Travis Air Force Base in California was selected as the

site for implementation of Phase II. The organization and the planning of this project

are discussed. The beneficial occupancy of the Phase II, Travis Hospital is scheduled

for 1977.

Keywords : Architecture; design; hospital design; medical facilities; military construction; new generation military hospital; system design.

1
The Department of Defense (DoD) and the Military Departments, from time to time, do make contributions to the welfare of the Nation in the way of spin-offs from our own

R&D efforts in the development of things for our own requirements. For example, we have

been responsible for the development of: Fire retardent paints - fiberglass screening - infrared photography - and even the

caterpillar earth movers are patterned after Army tanks.

In recent years - starting with Secretary of Defense McNamara's prodding, the

Department of Defense has been involved in developments which not only would have

benefit to the Defense Department, but to the Nation as a whole on a social basis.

Recent examples have been in the field of industrialized housing. Additionally, we have

invited industry to use our vast housing and building inventory as a test bed for trying

new products or to dramatize items to convince building authorities of their merit.

The discussion item of today is in the same view. Worldwide, Defense has some 240

major hospitals and 460 dispensaries serving over 10 million people and employing about

one quarter of a million medical and allied personnel. This medical logistical set up costs about $1^2 billion annually to operate, plus $60 to $100 million more for the

annual capital investment of new construction, alterations and installed equipment.

So, it was natural that we take some initiative in this area to make it both

responsive efficient and cost effective.

The Department of Defense, along with the entire medical profession, has been

greatly concerned with the increasing cost of medical care, both with the in-house and

ambulatory beneficiaries.

The Surgeons General are reasonably satisfied with the high quality of care that

the beneficiaries are receiving. But realizing that everything is subject to improvement, late in 1968 Secretary Clark Clifford announced that we would take a leadership

role via a new investigative project, entitled A New Generation of Military Hospitals

with a number of objectives in view:

The first of these was to develop a health care delivery system that would be mbre

efficient, diminish operating costs, and at the same time not only maintain, but,

hopefully, improve the quality of care of the recipients. To satisfy this objective,

it was envisioned that a significantly changed hospital model would evolve, and include

all of the features embodied in a hospital of advanced design with particular emphasis

on the exciting assistance offered through electronics -- both with computer techniques

and communications.

The medical departments of the Army, Navy and Air Force have already been pioneering

in the field of automation in various areas -- some concentrating on the laboratory

phase of automation with mul ti channel ed devices, some concentrating on the business

management end and the cost disbursement area, others have experimented in communications, transport of material, flexible facility design and construction -- and the

development of centralized or regional registries.

In essence, then, what we are doing is not absolutely new -- But, it does represent

the first effort of this scale to combine and assimilate in an orderly fashion, in one operating medical facility, as many of these existing, proven, practices which can be

cost-effectively married.

2
The Office of the Assistant Secretary of Defense (Health and Environment) prepared

a formal project proposal calling for a two-phase effort as follows:

Phase I : This was to be a systems analysis study of hospitals, military

and civilian, with a view toward reducinn life-cycle costs at no reduction in the quality level of patient care. Primary responsibility for this phase would

be the Office of the Director of Defense Research and Enqineerinn (DDR&E).

Phase II : This would consist of the desion and construction of a test

bed military hospital for the purpose of i ncorporati no and evaluatinn the

recommendations emanatinq from Phase I. Primary responsibility for this

phase would rest with the Office of the Assistant Secretary of Defense for

Installations and Looistics (in which I work).

In early 1969, Secretary of Defense Laird (you see, there were a lot of players in the act -- first McNamara, then Clifford, and now Laird -- but all with the same objective) gave approval to the project, and work was bequn on Phase I. A request for

proposals went out to industry and 28 consortiums, representing just about everyone

well-known in the systems analysis and medical planninq business, responded. From this

group, 7 firms were selected for interviews and, finally, contracts were signed with

two consortia -- one headed up by the Westinqhouse Electric Corporation of Pittsburg

with the architectural firm of RTKL from Baltimore, and medical consultants from Johns

Hopkins University, and the other qroup was headed by Arthur D. Little (ADL), Incorpora

ted of Cambridqe, Massachusetts with Lester Gorsline Associates - SRS Consultants and

the architectural firm of Campbell, Aldrich and Nultry from Boston. It was intended

by DORSE to sign up as many as three separate firms in order to get divergent views on the subject, for about a total of Sih million. However, the available funds would

permit only two contracts -- actually these two contracts cost about $1.7 million

($780,000 + $900,000).

Over the year in which the contractors conducted their studies, regular progress

reviews were held by a mu 1 ti d i sc i pi i nary panel with representatives from various parts

of the Office of the Secretary of Defense, includinn Research and Engineerinq, Health

and Environment, Installations and Loqistics, Systems Analysis, the Comptroller, the

Military Departments, and representatives from Health, Education and Welfare, and the

Veterans Administration.

The two contractors finished their work and submitted their reports by May 1971.

At that time, a Tri-Service panel with both medical and engineering members, reviewed

the studies and extracted all of the recommendations. These came to 259 items.

However, after further screening and consolidation of items, a net list of some 80

major recommendations evolved to be included in the new facility. There were, of course, other recommendations -- some which were appropriate for immediate application

to retrofit situations; some which required policy decisions, such as extended (evening

and/or weekend) hours for the outpatient clinics; and still others which will require

continued R&D effort.

Among the more prominent recommendations accepted were:

1. Develop a completely comnuterized hospital system, drawinq from the many exist

ing fragmentary systems now in use at certain military and civilian hosoitals.

2. Utilize the convenience food system and provide in-house preparation of the

convenience food stock.

3
3. Develop light care nursing facilities, primarily for the category of patients

who are not seriously ill, but are not well enough to go back to duty -- and those who

have been admitted but are ambulatory and need not be confined to bed. I will discuss

this light care aspect in more depth a little later, because of its magnitude and

potential impact on costs.

4. Develop outpatient surgery to achieve savings in the number of beds required.

This, as most of you know, is becoming increasingly popular throughout the private

medical sector.

5. Develop physician assistants program to achieve a higher utilization of scarce professional staff. Such programs are underway -- but should be intensified.

6. Use multiphasic testing.

7. Extend the use of high cost clinical and operating facilities for more efficient

utilization. (Longer hours - not a problem with the professionals, they can be directed, but there is a problem with administrative and clerical staffs).

8. Use the demand model, a computerized method of developing and predicting the

specific requirements for medical facilities. A proper demand model cannot be downplayed in its importance, it will give you the specificity of current and expected

demands in each area of required health services.

9. Design the physical plant so that it is susceptible to both expansion and/or

alteration with little or no adverse impact to its daily operations. The two contractors had vastly differing ideas of how to accomplish this.

Lester Gorsline (working with ADL), as most of you know, is an interstitial space

man -- RTKL (working with Wes t i nghous e ) seemed to combine the best of several functional

designs we have been exposed to recently -- limited use of interstitial space, emphasis

on vertical utility cores, and a minimal number of structural components reused in a very repetitive manner.

10. Establish an Evaluation Board of authorities with expertise in both hospital

management and facility design to evaluate the merit of the end product.

The Department of Defense Medical Planning Review Board, which annually updates

the Military Departments' Five-Year Construction Plan, in April 1971 designated the

Travis Air Force Base Hospital, proposed for fiscal year 1975 funding, as the test bed

hospital for Phase II development. Travis AFB was selected over the other candidate

projects proposed because:

- Of the inpatient bed requirement of about 600 beds.

- (Actually there is an additional requirement of another 160 beds as a staging

facility in support of Air Force's air evacuation program.)

- There is an outpatient load of approximately one-half million visits per year,

- It is near the Davis Campus of the University of California, which has a medical

school, so there is teaching capability.

- And the proposed Travis hospital, which is actually a replacement facility, is of

high enough priority to insure that it will be included in the annual legislative

program

.

Deputy Secretary of Defense, David Packard, at that time made the further determination that this phase should be handled under the Defense Systems Acquisition Review

Council model of management. Under this system, a single manager is designated and

tasked to carry out the total effort, and he, in turn, reports to a high level council

4
composed of three Assistant Secretaries of Defense, namely that for Installations and

Logistics, Health and Environment, and the Comptroller. I have been designated to serve as the Executive Secretary of the Council.

The Air Force, as owner of the Travis AFB hospital, has been designated to assume

the Program Manager responsibility. Deputy Assistant Secretary of the Air Force for

Installations, Lewis E. Turner, was named by the Air Force to be the Program Manager.

Under his direction. Colonel Roy Lemons has been designated as Special Projects Officer.

(See Figure 1.)

The Program Manager is presently administering three sub-tasks as follows:

1. By contract with Westinghouse Electric Corporation, an analysis of the beneficial population to be served, a quantification of the medical missions, and a documentation of the total project scope and cost. The end product is referred to as the

Demand Model. We are also planning to enter into a supplemental contract with

Westinghouse to have them develop a handbook -- a step by step guide for the development of a Demand Model for the general use by the Military Departments and any other

interested Federal agencies.

2. A second contract is with Benham-B 1 a i r , an architectural firm from Oklahoma

City with much expertise in the design of medical facilities, for a review of existing

DoD medical facility criteria, a review of the Phase I study recommendations, and the

development of a total design guidance package. This includes a review and recommended

changes to the Class A & B equipment lists. With the recent demise of Office of

Management and Budget (0MB) Circular A-57, an extra responsibility has been placed on those Federal agencies involved in the design of medical facilities or for the issuance

of design criteria covering the design. Of import also, is the currency of the

equipment lists; that is, what is to be contractor furnished and what is to be Government furnished and contractor installed. As many of you know, as soon as a contractor

is given the award, he shops around for his equipment to install. The warranty starts

upon delivery -- and it may not be put in use for two years or more. Additionally,

certain items are undergoing design advancements -- and if they are purchased 2 or 3 years later, a more advanced model becomes available.

3. The third task being undertaken by Air Force is an in-house analysis of medical

facility computer software, available to both the military and to the private sector

-- worldwide -- including a compilation of state-of-the-art components and development

goals for use at the Travis AFB test bed hospital.

The first two tasks, the Westinghouse Demand Model and the Benham-Blair study, are approaching completion at this time, and the software program is a continuing effort

with no fixed termination.

At this point, permit me to elaborate on the Demand Model and its findings. A careful analysis indicated that Travis serves a geographic area with a radius of about

25 miles. This includes active duty personnel, their dependents, military retirees

and their dependents. Bed demand was based on an 80% occupancy rate and clinical

visits based on actual count (excluding immunizations). The data were broken down to the speciality distribution and resource requirements. Be mindful that we are addressing all kinds of services from pediatrics to geriatrics. The base data reflected

1972 -- and these were then projected for 1975, 1980 and 1985. Projections were based

on known population growth patterns and the historical, recent experience in type of

specialities being served and the trends of each. The bed requirement for 1972 was

594, for 1975 - 617, for 1980 - 648, and for 1985 - 668. Because of the 20% factor of

5
PHASE II MANAGEMENT STRUCTURE

NEW GENERATION MILITARY HOSPITAL PROJEC

ACQUISITION REVIEW COUNCIL - OSD ASD(I&L) - Mr. Shillito, Chairman

ASD(H&E) - Dr. Wilbur

ASD(C) - Mr. Moot Executive Secretary (I&H) - Mr. Gerber

TECHNICAL ADVISORY PANEL

Arch - E n g r D i v Medi ca

1

Di V Chmn - I&H Chmn - H&E Mbr s - Army Mbr s - Army

Navy Navy

AF AF

OSD MEDICAL ADVISORY COUNCIL

Hospital Planning Subcommittee

Dr. Kenneth B. Babcock

Dr. James E. McCormack

AF PROGRAM MANAGEMENT COMMITTEE

SAFILI - Mr. Turner, Chairman

AFSG Lt. Gen. Patterson

AFPRE - Maj . Gen . Rei 1

1

y

SAFMRP - Mr. Goode

AF SPECIAL PROJECT OFFICE AFPRE - Col. Lemons, Project Officer

Staff - Medical Officer - Engineer Officer

Others as Required

DESIGN & CONSTRUCTION AGENCY NAVFAC

Design Operation Group - Hq NavFac

Constr Contract Office - WestDiv, NavFac

FIGURE 1

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occupancy rate and because the physical plant is to be susceptible to alteration and/or

expansion, it was determined that the bed size should be 500. Broken down by level of care:

I wish to highlight the light care demand -- 217 beds or 36.1% of the total. Because

this hospital serves the military, the flexibility requirement to accommodate emergencies

is basic -- but to what degree should this be accomplished? In other words, to what degree should light care rooms actually be designed and equipped as moderate care nursing units? Certain die-hard military medics say it should be 100%, the overwhelming

majority, however, say "maybe as much as 50% in this range of magnitude." Fifty

percent of 217 beds is approximately 100 -- of 20% of the total 600 bed requirement -- which need only housing accommodations, maybe something like a hotel or motel room -- and maybe not even a nurses' station. This potential represents hard, life-long savings.

The final decision on this aspect has not yet been made.

The design development is underway with the Westinghouse and Benham-Blair efforts

being the initial phases, but the methodology is not in the usual mode for the development of military medical facilities. The normal development is in four stages - see Figure 2. The design normally evolves from the Demand Data; this data is translated

into space requirements; the spaces are then configured into a Block Plan or an Adjacency Model (from which the preliminary or budget estimate is made); and then all this is developed into working drawings and contract specifications. The important

things to note are that 1) the Demand Data are usually limited to a review of records

and a rather unsophisticated forecast of future requirements, and 2) the conversion

of the Demand Data to a Space Program is a rather mechanical process of using tables

and criteria published in Defense Instructions which implemented 0MB Circular A-57.

Additionally, there is a current limitation that the gross area, for circulation and

the plus dimensions to make the individual spaces fit into a workable mass, cannot

exceed the net space criteria of the individual area by more than 15%.

The development of the New Generation Military Hospital at Travis is being handled

differently -- and for obvious reasons. The chore of validation and getting all the

necessary blessings at each milestone as we go downstream in each phase, has become

an acute exercise in critical path scheduling (See Figure 3). The Demand Model is much

more sophisticated in its survey techniques and projections; then instead of translating

each of the requirements of the Demand Model into space requirements from existing

criteria - each listed space in existing criteria was questioned as to its currency and

appropriateness in the context of the New Generation effort. Of course, any changes to existing criteria have to be concurred in by both the Air Force Surgeon General and

Defense, with Defense taking its action after consideration by the Technical Advisory

Panels. This critique of existing criteria is being referred to as the Preliminary

Study. Once the Preliminary Study is completed, then it is converted into a Block or Adjacency Plan solely for the purpose of developing a Budget Estimate. This space study

is being called the Preliminary Concept.

Concurrently with these aforementioned studies, the Air Force's Task Group at Gunter Air Force Base has been working on the software developement and feeding in its

Intensive Care

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findings and recommendations as to space and power requirements to Benham-Blair so that

the Block Plan and Budget Estimate can reflect the hardware requirements. Hopefully,

these latter requirements will be sufficiently locked-in before Final Concepts are started

.

All the work to this point is under the direct purview of the Air Force. With the

completion of the Preliminary Concept and Budget Estimates, the development of the

Final Concept and the working drawings and specifications become the responsibility

of the Naval Facilities Engineering Command CNavFac). Within the framework of the

management structure I spoke about earlier NavFac is the Design and Construction

agent

.

At the present time, NavFac is involved in the selection process for the ArchitectEngineer CA-E) firm, or combine, which will develop the Final Concept and the contract

working drawings and specifications. The Selection Board is working within certain

guidelines in their considerations. The objective is, of course, to select the "best

qualified" whether or not that firm has had previous experience with the Military

Departments. The considerations, or guidelines, include the following: (See Figure 4) The firm's demonstrated experience and expertise in -- Medical and health care planning

Generalhospitaldesign

Teaching hospital design

Workload, existing and projected

Adequacy of staff and in-house capability

Management, including success in cost estimating

Seismic design experience

And of course -- The type of organization in this particular venture; whether it be an A-E firm with consultants, or a joint venture, and

Previous experience with Federal projects.

NavFac started out with a list and files on about 250 A-E firms who had either

expressed interest in the project, or were known to have some expertise in the matter.

The initial screening reduced the list to something over 60 firms. A second screening

further narrowed the list to some 23 firms -- and then further evaluations were made

to a final list of 10. These 10 firms will be very carefully considered, their offices

may be visited, and some may be requested to make presentations. The final selection

will name the top 3 firms in priority order -- and after approval of this selection

by the management structure, fee negotiations will take place with the number one firm.

Final building plans are scheduled for completion in late 1974, and beneficial

occupancy of the hospital is scheduled for early 1977. FY 1975 military construction

funding is proposed.

A word about the cost estimate -- that is, as of this time. Original ball-park

estimates put the project at about $65 million:

$40 to $45 million for the physical plant and site development;

and $15 to $20 million for the electronic hardware.

The current cost estimate, reflecting the Westinghouse and Benham-Blair studies

point to $100 to $105 million:

$70 to $75 million for the plant and site development;

10
ARCHITECT -ENGINEER QUALIFICATIONS

The following items will be considered in selection of an architect-engineer firm for

the design of the New Generation of Military Hospitals (N6MH) Project, Travis Air

Force Base, California:

Medical and Health Care Planning

Hospital Design

Significant Projects of Similar Scope to NGMH Percent of Total Effort In this Area Awards and Recognition for Hospital Designs

Availability of Consultants

Workload, Existing and Projected

Adequacy of Staff and In-House Capability

Management

Experience with Fast Tracking Construction Management

Experience in Incremental Design

Success in Cost Estimating

Organ i zat ion

Type of Organization

Previous Accomplishments of Joint Venture (if applicable)

Integration of Architectural and ECapability

Seismic Design Capability

Previous Experience with U. S. Government Projects

n
and $25 to $30 million for the electronic hardware.

In summary, the difficulties and risks associated with this project arise not so much from the fact that it is a direct attack on and utilization of the state-of-theart health care delivery systems, but rather that it entails the ultimate integration

of a number of state-of-the-art functional systems into a single cohesive system that

not only satisfies the medical requirements of the Travis Medical Center, but also

provides a flexible test bed for the accomplishment of f ol 1 ow-on-systems , procedures,

and methodologies. But it is exciting and challenging -- and, hopefully, it will

have manifold returns to the taxpayers for the investment involved.

12
NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Gai thersburg , Md. (Issued July 1 974)

Rationale for Change--The Hil 1 -Burton Program

John W. Reese Chief, Architectural

Office of Architecture and

Branch

Engineering

Health Care Facilities Servi ce Health Resources Admin i s t r a t i 0 n Department of Health, Educati on and Welfare

ABSTRACT The Hill-Burton Program was established in 1946 for the financing of needed

health facilities in the United States. An important function of the Hill-Burton

Program is the continual updating of minimum construction requirements with which

Hill-Burton projects must comply. Many States, architects, and engineers use these

requirements for all health facility construction. Some of the newly proposed

changes described include modification of Fire Safety requirements to make them

compatible with other government agencies; improved parking facilities; increased

emphasis on making health facilities accessible to-the physically handicapped; a new section for intensive and coronary care units, and a new section dealing with natural

disasters. Government building regulations will continue to change, probably in the

direction of making the environment more livable and in the increased concern for

conserving human resources.

Keywords : Architecture; building regulations; construction standards; design;

Hill-Burton; hospital design; medical facilities.

13
RATIONALE FOR CHANGE--THE HILL-BURTON PROGRAM

The National Bureau of Standards 1s to be complimented for sponsoring these Federal

Workshop Seminars where different agencies concerned with similar programs can communicate. Understanding each other is the first step in coordinating efforts and

eliminating conflicts.

I. What is Hill-Burton?

For those of you not familiar with the Hill-Burton program I have passed out a "Fact Sheet" (See Attachment). This outlines the impact that this legislation

has had in obtaining needed health facilities throughout the United States since

its inception in 1946. The Health Care Facilities Service, a unit within the

organizational structure of the Department of Health, Education and Welfare (DHEW),

is responsible for administering the program. The Office of Architecture and

Engineering has the major responsibility for developing minimum construction

requirements for Hill-Burton projects. Since this audience represents Federal

construction programs in the health field, I want to outline the proposed changes

in these requirements and the rationale for these changes. Community hospital

problems, of course, differ in several respects from those confronting Federal

facilities. For example:

A. Most Federal hospitals exceed 500 beds while most Hill-Burton

hospitals fall in the 50 to 200 bed range.

B. Most of the personnel in Federal facilities are drawn from the military

establishment while personnel in Hill-Burton facilities are hired at market prices.

C. Federal facilities are regionally oriented while Hill-Burton facilities

serve local communities.

Despite these and other differences, you may find that our requirements can be applied

to your hospitals in many ways.

II. Who uses Hill-Burton requirements?

State and regional Hill-Burton personnel as well as Regional Offices of Facilities

Engineering and Construction Agency (ROFEC) which oversees Hill-Burton projects.

Architects and engineers find they serve as guidelines in designing all kinds of

health facilities -- regardless of whether they received Hill-Burton assistance. Many

States have adopted these requirements as the State regulations governing all health

facility construction.

III. Why do we need these requirements?

First and foremost, they serve as an educational tool and are considered an invaluable

aid by hospital architects and engineers. Unfortunately, there are some hospital

sponsors who are willing to let the dollar dictate design regardless of the inefficiencies of operation or hazards to the patient. The requirements then become a club

14
to enforce adequate facilities. As many of you know, variations are permitted when the

program or design assures us that the intent is not being violated.

IV. Who is responsible for keeping the regulations up-to-date?

This is the responsibility of the Health Care Facilities Service with the focal point

being the Office of Architecture and Engineering. However, representatives of many

different disciplines and organizations give us their recommendations on each item. These

consultants include private practicing architects, engineers, physicians, hospital

consultants, plus representatives from the American Hospital Association, State HillBurton agencies, and ROFEC.

V. What other Government agencies are consulted?

Representatives of various other Government programs attend meetings to give advice

to bring about better coordination with their agencies. These include the Facilities

Engineering and Construction Agency (FECA), the Department of Housing and Urban

Development, and the Social and Rehabilitation Services. Unofficially, we obtain ongoing

input and communication from the Bureau of Radiological Health, the National Bureau of

Standards, the Veterans' Administration, the National Institutes of Health, the National

Center for Health Statistics, and the National Center for Health Services Research and

Devel opment

.

After proposed updating has been reviewed and revised, we send copies to all State

agencies, regional offices, and many practicing architects and engineers involved in medical facility construction. All comments are evaluated for inclusion in the final

document

.

VI. Why are changes needed?

A. One rfeason for updating our requirements is to accommodate the Nation's changing

emphasis in the delivery of health care. Today the emphasis is on outpatient

services, preventive medicine, and sharing concepts rather than on facilities for

inpatient care. For example, during fiscal year 1972, nearly half (47 percent) of

the 191 projects approved for Hill-Burton grants were for construction or modernization of public health centers, outpatient facilities, and rehabilitation facilities.

This compares with 37 percent in 1971, 29 percent in 1970, and 24 percent in 1969.

Sharing of resources by health facilities continued to be encouraged through the

incentives provided in the 1970 legislation and through the Joint Project Support

concept developed with other health programs. Maximum flexibility in the use of

construction support funds was furthered by giving higher priority to projects which

relate to other DHEW programs such as those concerned with health maintenance

organizations, comprehensive health care, neighborhood health centers, maternal

and child health, family planning, drug abuse prevention and care, and alcoholic

rehabilitation. These priorities are reflected in our new requirements.

15
B. The second reason is the advancement of new programs and procedures, either

dictated by Congress, required by the medical profession, or demanded by patients.

Minimum requirements for the construction of intensive care units are but one exampl e

.

C. The third reason for change is to keep abreast of new technology, equipment,

and concepts. New electronic devices, new safety equipment, and new concepts

such as outpatient surgery and combining obstetrics with operating suites are several examples.

VII. What are the major changes?

The major changes in our proposed regulations may be grouped under four headings:

A. Fire Safety. Our fire safety standards have been changed so that they are now compatible with those of other Government agencies. We propose that construction

shall be in accordance with the requirements of section 10-132 of the latest

National Fire Protection Association (NFPA) Standard 101. Interior finish

materials shall comply with the flame spread limitations for walls and ceilings in exitways, storage rooms, and areas of unusual fire hazards according to American

Society for Testing and Materials (ASTM)-E84 Standards of 0-25-, in other areas

0-75. Floors shall have a rating of 4 or less and comply with Underwriters'

Laboratories (UL) Standard 992. Smoke production for wall and ceiling finishes

shall not exceed a 350 rating as established by the ASTM-E84 Standard. Smoke

production for floor materials shall be 350 or less by E94 or 450 or less by the

National Bureau of Standards' smoke chamber.

B. Parking for hospitals and other health facilities. Each facility shall have

adequate parking to satisfy the minimum needs of patients, employees, staff,

visitors, and emergency and delivery vehicles. In the absence of a formal parking

study, each facility shall provide not less than one space for each day shift

staff member and employee plus one space for each patient bed. This ratio may be

reduced in an area that is convenient to a public transportation system or to public parking facilities if proper justification is included in the narrative

program, and provided that approval of any reduction is obtained from the State

Hill-Burton agency. Additional parking may be required to accommodate outpatient

services and other services when so specified in the narrative program.

Parking requirements for long-term care facilities would be the same as for hospitals

except that not less than one space should be provided for each day shift staff

member and employee plus one space for each five patient beds.

Vehicle parking for outpatient facilities shall be provided at the ratio of two spaces for each treatment and each examination room plus one space for each staff

member

.

For rehabilitation facilities, parking capacity shall be provided at the ratio

of three spaces for each professional staff member. The same escape clauses as indicated for hospitals are also included.

16
C. Special design considerations for the handicapped (patients, staff, and

visitors)

.

As set forth in Public Law 90-480, "Design and Construction of Public Buildings

Financed with Federal Funds to be Accessible to the Physically Handicapped," such

design considerations are required for all public buildings which receive any part

of their funding through Federal grants or loans. The following items are listed

to augment, clarify, or emphasize some of these special design elements:

1. Walkways and curbs shall be planned to facilitate travel by people in wheelchairs or on crutches.

2. Signals, such as elevator calls, shall be both audible and visible.

Elevator control buttons shall be accessible to wheelchair occupants.

3. Not less than one percent of all parking spaces provided for the project

(with a minimum of two spaces) shall be planned and set aside for the

handi capped

.

4. Design shall consider the needs of the user having physical impairments

with special attention given to the shielding of sharp projections,

moving parts, and heated surfaces.

5. Facilities such as drinking fountains, toilets, and handwashing shall be

available on each public floor and designed to be accessible to the

public and staff as well as patients who are physically handicapped.

6. Minimum requirements not otherwise noted in these standards shall be those set forth in American National Standards Institute (ANSI) Publication No . A-11 7 . 1 .

D. Shared services: Obstetrics and Operating Room (OB - OR). Services shall

be arranged to avoid traffic between the surgery and delivery rooms. OB service

areas may be shared with and organized as part of the surgical facilities if the

approved program reflects the sharing concept, except for the following:

Sterilizing and scrub facilities located in either or both departments

will not be shared with the other. Soiled work or holding room(s) shall not be shared, A janitor's closet -- a closet containing a floor

receptor or service sink and storage space for housekeeping supplies and

equipment shall be provided for the exclusive use of the obstetrical

suite and another for surgery.

VIII. Major additions to the requirements include:

A. Freestanding outpatient facilities, for the first time, are being regarded as office buildings insofar as fire safety regulations are concerned. These facilities

therefore are removed from the institutional classification where they have always

been. They now conform to the NFPA definition for non i ns t i tut i ona 1 occupancy.

B. A special section of the requirements relates to the design of intensive and

coronary care units. Although not a particularly new concept, the rate at which

they are being incorporated into hospitals dictated this addition.

17
C. From the new section on natural disasters, I will quote directly since most of

you are also re-eval uati no your criteria:

"1. Earthquakes . In regions where local experience shows loss of life or damage to buildings resulting from earthquakes, buildinos or structures shall

be designed to withstand the assumed force by conforming with criteria set forth

in the latest issue of the Uniform Building Code (UBC).

In buildings which are subdivided into separate structural units by seismic

joints, each unit shall be provided with an exit stairway to permit evacuation

from the building without need for traversing the seismic joints.

Special care shall be taken to anchor fixed equipment, suspended ceilings,

light fixtures, and similar items to minimize hazard to occupants and damage

to the equipment and building during an earthquake. Storage shelves and racks

holding breakable or fragile supplies shall be designed to retain their contents

when subjected to the lateral forces of an earthquake.

"2. Hurricanes, tornadoes, and floods . Special provisions shall be made in the

design of buildings in regions where local experience shows loss of life or damage to buildings resulting from hurricanes, tornadoes, or floods.

"3. Communi cati ons . An emergency radio communication system shall be provided

in each facility. This system shall be self-sufficient in time of emergency and

capable of operation without reliance on the building service or emergency

electric power supply. It shall also be linked with the available community or State emergency communication network, including connections with police and

fire systems."

IX. What of the future?

In spite of what we think we know about medical facilities, the only thing we know for

certain is that they will change. They must change as the systems for health delivery

and the needs of people change. To be sure, the metamorphosis will be slow but I see signs of changes already upon us. One in which Government regulations are just getting

their feet wet is the environmental impact statement. Mays must be found -- and soon

to slow man in his efforts to destroy the livable qualities of this spaceship earth.

The other thing I see in the immediate future is the grouping of buildings and programs

which deal with human resources. Let me give you an example:

In South Dade County this year I viewed a group of temporary buildings

which housed various types of services for the area's migrant workers.

The director told me this story: A worker came in one day and reported

that he was too ill to work. A medical examination in the clinic

revealed that insecticides had infected the man's respiratory system.

18
Upon questioning by the director, it was found that the farmer did not provide the workers with masks while they were spraying. Although the

farmer promised to change the job of the worker under treatment and

provide masks, the worker reported to the clinic the next day to say he was out of a job. The director went next door to the welfare agency to provide him with money to live on, then took him next door to the Public

Health Clinic for immunization shots. Furthermore, he contacted the State

official responsible for enforcing State laws dealing with the use of

poisons and insecticides to force the farmer to provide the proper

safeguards. Lastly, the director treated this migrant worker until

he was again able to return to work Cwith the help of the employment

agency) .

I mention this story to illustrate a few of the many services necessary to enable a person to operate at his optimum ca pac i ty -- - phys i ca 1 ly and mentally. When these

services are scattered all over the city, it not only prevents coordination but reduces

their availability to the very people needing them most.

While we in Hill-Burton are proud of the program's long list of accomplishments, we are the first to admit that solutions to most health problems (particularly those with

related socio-economic overtones) contain the seeds of many others. It is the program's

flexibility that has enabled it to come up with new solutions to keep pace with the

times. This flexibility may be the particular attribute which inspired the author of

an article in the September 1970 issue of the American Journeil of Public Health to write;

"When the history of health legislation in the 20th Century is written, the place

of honor as the most significant single piece of Federal legislation may well be

accorded to the Hill-Burton Hospital Survey and Construction Act of 1946, at least until the era of a national health care program arrives."

19
ATTACHMENT

November 1972

FACT SHEET

THE HILL-BURTON PROGRAM

HILL-BURTON OBJECTIVES

Better patient care for all the people through the provision of appropriately

designed health care facilities has been a major objective of the Hill-Burton Program

since its inception in 1946. Some prime functions have included:

(1) the development of better planning methods to aid communities assess their

overall needs and determine areas requiring greatest priority;

(2) the elevation of standards of design, construction, and operation of facilities through the provision of consultation services which includes the development of

guide materials widely used not only in this country but by health facility planners

around the worl d

;

(3) financial assistance for the construction and modernization of various types

of public and private nonprofit community health facilities. In addition to its longstanding grant program, Hill-Burton also provides loan guarantees with interest subsidies to nonprofit hospitals and direct loans to public hospitals.

PROGRAM SUMMARY

Keeping abreast of the Nation's fast changing health needs so that new directions

could be instituted as needed has characterized Hill-Burton over the years. As a pacesetter, the program has scored many "firsts" and continues to look for better ways

to help resolve the Nation's many health delivery problems.

Examples of innovations introduced by Hill-Burton include: Statewide planning

which identifies needs on a priority basis; establishment of areawide planning agencies

which ultimately led to comprehensive planning; establishment of minimum standards for

construction, maintenance, and operation of health facilities which are continually

updated; development of guide materials in functional programming, equipment, design,

and hospital environment; and providing impetus to the sharing concept through grant

i ncenti ves

.

Amid ever-increasing changes in the health delivery system, the Hill-Burton program

was redirected by new and significant legislation to meet the demands of the 1970s. The

1970 legislation extended the grant program and incorporated a number of innovations

including provisions for loans and loan guarantees to provide greater flexibility in assisting the States to meet their community health needs.

20
The legislation also took cognizance of the need to emphasize out-patient facilities

to lessen demand for more expensive inpatient facilities and to hold down the cost of

health care to the patient. Thus, the current major thrust of Hill-Burton activities is aimed at the expansion and improvement of outpatient care. The annual authorization for

outpatient facilities was increased from $20 million to $70 million, and for the first

time Hill-Burton funds became available for the construction of freestanding outpatient

facilities such as neighborhood health centers. Priority must be given to outpatient

facilities for poverty areas, and the Federal share may be increased to 90 percent of

the project cost for projects in such areas.

Other projects which may receive up to 90 percent of the cost in Hill-Burton funds

are those involving facilities which offer potential for reducing health care costs through (1) shared services among health care facilities or (2) i n ter f ac i 1 i ty cooperation.

Other special priority categories include projects which will provide comprehensive

health care, training in health or allied health professions, and treatment for alcoholism. Also, at the option of the State, priority may be assigned to projects serving

rural communities. Other new provisions include:

1. That a hospital project approved for Federal assistance must make arrangements

to provide extended care services.

2. That health professions education or training facilities operated in connection

with a hospital are eligible for assistance.

3. That Federal assistance is available for purchasing equipment for existing health

facilities if the equipment will provide a service not previously provided in the

communi ty

.

HOM THE PROGRAM IS ADMINISTERED

State Hill-Burton agencies administer the program at the State level, while the

Health Care Facilities Service has administrative responsibility for the overall

National program. HCFS staff in the 10 HEW Regional Offices have project approval

authority and work with State agencies and Central Office to assure that Federal

requirements are met.

The State administering agency is the initial point of contact by those seeking

Federal financial aid and consultation services.

HILL-BURTON GRANTS

As of July 1972, more than 10,900 projects had been approved for the construction

or modernization of over 6,300 public and voluntary nonprofit facilities serving 3,800

communities throughout the country. Some 477,000 inpatient beds were provided for

hospitals and nursing homes. The total cost of these projects was $13.2 billion, of

21
which the Hill-Burton funds were $3.8 billion. The matchinn funds of $9.4 billion were

provided by State and local sources.

HILL-BURTON LOAN AND LOAN GUARANTEES

The new Hill-Burton loan and loan quarantee programs, for which final regulations

went into effect in January 1972, have made loan agreements and tentative allocations

totaling $241.2 million with facilities in 95 communities during its first six months

of operation. Actions under these new programs include two endorsements for a total

of $5.2 million; 28 commitments totaling approximately $83 million; and 81 tentative

allocations totaling approximately $153 million.

Loan guarantees with interest subsidies may be made to provide nonprofit agencies

and direct loans to public agencies to aid in modernizing or constructing health care facilities. The legislative authorization provides that loans totaling $500 million

may be guaranteed annually, or a total of $1.5 billion over the 3-year period covered

by the statute.

Loan authorizations are allotted to the States on the basis of relative (1)

financial need, (2) population, and (3) need for additional or modernized health facilities. The loan, or a combined grant and loan, may not exceed 90 percent of the cost

of the modernization or construction project.

CONSULTATIVE AND TECHNICAL SERVICES

An important feature of the Hill -Burton program since its inception has been the

consultative and technical services provided on the State and Federal levels. Consultation is provided in such areas as architecture, engineering, equipment planning,

nursing, dietetics, pharmacy, central service, health education, and environmental

health and microbiology.

Over the years, consultation has been provided by letter, telephone, personal

visits, lectures, and participation in conferences and workshops. In addition, guidelines are published on many phases of design, construction, equipment, and operation

of health facilities.

The program also conducts conferences on environmental health and infection control, dietary facilities, nursing service administration, medication distribution,

central service, preventive maintenance, functional programing, and equipment planning

in various parts of the country to supplement individual consultation and speeches on

a variety of topics.

22
iMTIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES b4, Proceedings of tne First Federal Agency Workshop, December 5 , 1 972 , Gai thersburg , Md. (Issued July 1974 )

INTRODUCTION - Application of Advanced Technologies

to Hospital Design in the Veterans' Administration

Robert L. Rosenberry

Staff Assistant to the Associate Deputy Administrator to Veterans ' Af f ai rs Veterans' Administration

ABSTRACT The Veterans' Administration operates 168 hospitals, valued at five billion

dollars, containing approximately 100,000 beds and employing 153,000 people. To meet

the planning and construction requirements of such a health care delivery system

requires the application of advanced technologies.

Keywords : Design, hospital design; medical facilities; planning; technology; Veterans'

Admi n i strat ion

.

23
The topic. Application of Advanced Technologies to Hospital Design", was selected

for todays Federal Workshop in order to give you an overview of the Veterans' Administration' (VA) hospital system, and some idea of planning and design concepts. To do this, in the short time available, I will present some background data and then different members of our staff will discuss (1) "Space Planning Criteria", the basis for

establishing detail requirements; (2) "Use of the Computer in Planning Hospitals", a real application of work-load data being combined with computer capability to produce

planning documents, and (3) "VA Hospital Building Systems", a description of the

research study recently conducted and its application to projects presently being

des i gned

.

To give you a general idea of the scope of the health care system managed by the

VA let me cite a few facts. We operate 168 hospitals throughout the United States.

Their real property value is approximately five billion dollars. The cost of maintaining these facilities is about $70,000,000 annually. There are approximately 100,000

operating beds in these hospitals, which support an average daily patient census of

about 87,000. We employ 153,000 people in our Department of Medicine & Surgery and

have an annual appropriation of approximately $2.5 billion for this activity. We also conduct major Research and Education programs in most of our hospital facilities,

particularly those affiliated with Medical Schools. These programs and affiliation

requirements contribute to the mirad of details to be related in planning and modifying

the physical plants. The next part of this presentation will explain how these requirements evolve and are controlled in project development.

24
NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5, 1972, Galthersburg , Md. (Issued July 1974)

Space Planning and Equipment RequirementsApplication of Advanced Technologies

to Hospital Design in the Veterans' Administration

Howard J . Fogarty

Chief, Space Planning Criteria Staff

Department of Medicine and Surgery

Veterans' Administration

ABSTRACT Prior to 1958, the Veterans' Administration (VA) used a 500 bed prototype as the basis of all design and construction. This proved undesirable since almost all new VA hospitals were to be teaching facilites with widely varying requirements not well suited to any single prototype. At the end of the 1950's the Bureau of the

Budget issued the Federal Space Planning Criteria. The VA expanded and refined this

criteria and has been successfully applying it for over ten years.

Keywords : Criteria; hospital planning; medical fatilities; planning; Veterans'

Administration.

25
The Veterans' Administration (VA) operates the largest Health Care Delivery System

in the nation consisting of 168 hospitals and a number of outpatient facilities physically located both within and outside the hospitals. Since World War II we have

constructed many new and replacement facilities and modernized a number of our older

facilities. Prior to 1958, VA hospitals were designed on the basis of a 500 bed

prototype criteria. However, this approach was unsatisfactory since almost all of our

new and replacement facilities were to be teaching hospitals affiliated with medical

schools usually located adjacent to the university campus. We believe this trend for

medical school affiliation will continue in the future. The 500 bed configuration did not meet the needs for these projects. The wide variation in program requirements in the teaching hospitals made prototyping undesirable. At about that point in time,

Federal space planning criteria, which was prepared in the Bureau of the Budget with

interagency staff support, was published. Although it involved only major functional

areas, Federal criteria covered about 80% of the hospital space. Thereafter the VA expanded upon Federal criteria, refined it, and developed new criteria for those

functional areas not originally included. These criteria are published as VA Manual M-7

.

They have been used for more than a decade as a guide for planning all VA Health Care Facilities construction projects. The Office of Management and Budget has delegated

the space planning criteria to the individual agencies when the Federal Space Criteria,

BoB circular A-57, was recently rescinded.

At any point in time we will have approximately 300 major and minor construction

projects underway at various stages from preliminary planning through construction.

Many of these are projects involving space ranging from complete master plans for new hospitals or major hospital modernization to space plans for small projects such as construction of intensive care unts. In fiscal year 73, $180,993,000 was appropriated

for construction. To make the program more effective, funds for new and replacement

hospital construction are now being incremented in successive fiscal years; e.g., design,

one year, foundations and site another, building construction the following year.

The primary purpose of criteria is to serve as a tool for those who develop

construction projects at all levels in our organization. They provide an established

formula for determining the net space requirements for each functional area of the

hospital. Their application, utilizing such data as projected staffing and workload,

result in a space program or master plan dedicated to specific program needs as opposed

to prototyping. Applied criteria also serves as a budget tool by defining the scope

of the project in net square feet which in turn is converted to gross area. A current

cost index and escalation factor are applied and a total construction cost estimate is developed. The project master plan or space program also serves as the basic guide

document for the design of the hospital.

Master planning for a major hospital project is a tedious, involved, time consuming

process which may extend 6 months to a year into the project planning schedule. In order to shorten the time span and to relieve the project planner of numerous manually

accomplished computations, data research, and clerical tasks, considerable work has

been done in the past few years to utilize computer technology.

At this time I would like to introduce Mr. Bruce Keane of the Space Planning

Criteria staff. Health Care Facilities Service, Department of Medicine and Surgery, who

will tell you about this effort.

26
NATIONAL BUREAU UF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Gai thersburg , Md. (Issued July 1 974)

Use of the Computer in Planning HospitalsApplication of Advanced Technologies

to Hospital Design in the Veterans' Administration

Bruce D. Keane

Hospital Requirements Specialist

Department of Medicine and Surgery

Veterans' Administration

ABSTRACT In 1965, the Veterans' Administration [VA) began developing the facilities

Planning and Construction Requirements System to aid the VA in planning new facilities.

This system is presently in use today. This computerized system utilizes files

containing medical statistics, staffing, criteria and other information necessary for

hospital planning. This system produces a master plan. This master plan provides a listing of medical functions, projected staffing, space requirements and other information. After review and approval of this master plan, it is used by architects and

engineers for the design of VA hospitals. Future work on this system will include

provisions for equipment, addition of special environmental factors and extension

of the system to field station management.

Keywords : Computer-aided planning; design; electronic data processing; hospital

planning; medical facilities; planning; Veterans' Administration.

27
Some of you, I am sure, have heard speakers say they really had three speeches to deliver:

One they had planned, the one they gave, and the one they wish they had given.

It is possible that your questions, if any, at the end of this talk will make

number four - the one you wished I had given.

I have listened to four or five detail men that had been recently asked to talk

about their product. After telling us what we already knew, they would conclude by

saying, "We have the answer to the problem - I thank you."

We haven't a product so much as a service for our agency. It's an exciting project

and fraught with problems because of the complexity of the Veterans Administration

Health Care Delivery system.

The Facilities Planning and Construction Requirements system has resulted from

studies evaluating the use of the computer as support to management activities.

The system was designed to provide a master plan, listing the staffing, the amount

of space, and an abbreviated functional statement for each division or service in the

hospital . The system was originally designed for planning new facilities, although we have

tried to stretch it to plan modernization projects. We soon found that it required from

75 to 850 units of information to provide a complete plan. This information was already

available in other computer systems and we found a tie could have been made to interface

with other going systems.

After our limited beginning in 1965, we launched on what is called the " Expanded

Sys tem " in 1 969. (Short for we goofed and needed to start over). Early users of the

original system were disillusioned and unhappy with the results. After three years of

trial and error, and one year studying the feasibility in changing the system, we started

to correct the deficiencies of our original system which would provide the planning tools

necessary for developing projects.

Our toughest problem in developing a viable system was that of language. Believe

me, computer-types and hospital -pi anner types do not speak the same language, and an interpreter has been necessary.

Our system incorporates the use of the Automated Medical Information System (AMIS)

and the information included in Manual M-7 "Planning Criteria for Medical Facilities."

In addition we have developed and are conducting a space survey of all of our Health

Care Facilities to provide a profile of our agency's space utilization.

Also, we have a master equipment list; however, incorporating this list into our system will have to await phase two of the project scheduled to start in October of

1 973.

As I alluded to earlier, the language barrier created many of our problems in planning the sytem. To preclude this from happening here I would like to expain four

te rms : File - An organized accumulation of records stored in a manner compatible

with the system. We have five files: factor, function, profile, AMIS

and control . Function - Is a service, such as surgical, or supply service.

Module - The program for one function.

Field - The specific room, space, or workload factor within a modu

28
Our system is a marriaqe of workload to planninq specifications. We have accumulated three workinq files: the AMIS file, the function file, and the profile file; and

at a later date we will add an equipment file.

Planninq our medical facilities falls into three cateqories: new hospitals,

modernization or relocation of a hospital, and minor projects. Mew hospitals must be given all workload factors necessary to establish the whole project. We can use peer

hospitals to extract workload automatically from accumulated files, where appropriate.

Modernization or relocation hospitals use the AMIS data to provide the workload

and for some functions, we use a three-year accumulation to provide projections for

future planninq.

Minor projects, as with modernization, uses workload data for the existing hospital

to develop the space requirements for those functions included in the project.

The initial output we request from the computer consists of a project plan,

profile plan and control records; which we use to review, modify, and update the

appropriate fields. A significant deficiency in our planning is staffing and providing

for the number of students to be assigned to a given project. When planning facilities,

the student population is determined by the training programs with affiliated schools

and not directly by a predictable workload pattern. Medical program staffing guidelines

are available; however, program emphasis at a particular hospital creates variables of

the number of staff involved in specific functions.

It is then the responsibility of the planner to determine the projected staffing,

including the student population, and update the appropriate staff fields. When the

planner is satisfied that he has listed all the variables and provided for the special

programs, he will then request a master plan. This plan provides a listing of functions

with the projected staffing and space requirements, together with a narrative on some special environmental considerations. This plan is then reviewed by estimators and

other members of management. After its approval, it can be submitted to an architectengineer, or to the VA ' s own preliminary planning service for further graphic development.

If the project is a modernization, the master plan will provide a comparison

between actual space as assigned and as it should be in accordance with current space

criteria. Obviously, the space profile must be designed to allow for changes and

updates to assure that current data is used.

As previously noted, we are involved in a survey of all of our hospitals and

clinics. The survey is to be complete in April 1973, and each field location will

receive a listing of space as assigned by function. This list will include data

specifically programmed to be used by the engineering service in their maintenance and

repair program.

Our system only uses data from the profile that is necessary for comparing functional space requirements in manual M-7, or net square footaqe in each facility by

assignment. This information is displayed on a profile sheet for comparative purposes

during the planning process, as well as being inserted for comparative purposes in a master plan.

This profile will give us the ability to review space assignments in ten or twenty

surgical services including their comparative workloads. From this, the space criteria

in manual M-7 can be modified when necessary.

The system has a built-in factor update file, allowing overnight changes in space

allotments when criteria changes are approved.

29
The most important achievement is the cross-index of all of our functions allowing

for automatic adjustment when chanqes of workload occur. This feature retains the

interrelationships of the total hospital program so all functions can change if any

element of the workload changes. For example: addina 20 beds to a project will effect

support facilities from dietetics to the fiscal division. Our system will respond to this change and upgrade all functions to provide for the additional load.

Planning hospitals without the computer, or manually, often causes support services

to fall through the cracks, so to speak. In one 1000 bed hospital 200 beds had been

added without sufficient change in supporting facilities due to the pressure in planning

deadlines. This caused many modifications of programs and a modernization project

within 5 years.

The ultimate in building a master plan by computer will be the inclusion of special

environmental factors for all functions. To date, we only have included narrative

functional statements to a limited number of functions.

At a later date we anticipate this planning tool will be available to all field

station management, as well as central office planners, thereby providing a readily

accessible device for project development. We must realize that humans have the initial

input and responsibility for maintaining a current file and the system will be only as good as the criteria, workload data, and profile information imbedded in these files.

When we talk of AMIS workload and profile input, we are talking about hundreds of

thousands of bits of information used to complete the necessary records to accomplish

our goal of a computer-planned hospital. The advantage of the computer is its ability

to utilize these bits of information rapidly and provide a fast, dependable answer.

30
NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Gai thersburg , Md . (Issued July 1 974 )

Veterans' Administration

Appl i cat! on of Adva

to Hospital Design in the

Hospital Building Systemneed Technologies

Veterans' Administration

John C. Cook

Research Staff

Office of Construction

Veterans' Administration

ABSTRACT The Veterans' Administration (VA) Hospital Building System was begun to provide

new VA Hospitals with improved cost control, improved performance, increased adaptability, a reduction in the time to go from planning to beneficial occupancy and to provide

a system that could be continuously updated. The Building System is composed of three

parts; the data base, the planning modules and the building subsystems. The data

base contains the "user needs" necessary to determine functional and performance

requirements for new VA Hospitals. The planning modules are areas of space large enough

to accomodate a wide variety of hospital activities. Four types of planning modules

are used; a structural bay with a constant width of 22.5 feet (6.86 meters); a service

module of from 5000 square feet (464.5 square meters) to 15,000 square feet (1393.5

square meters); a space module, which is a sub-unit of the service module and a fire

section not to exceed 20,000 square feet [1858.0 square meters). The building subsystems

are the components of the VA Hospital Building System. Six subsystems have been developed

in detail; structure; partitions; ceiling; heat i ng -vent i 1 at i ng -cool i ng ; plumbing distribution; and electrical distribution. Advantages of the application of the VA Hospital

Building System include better response to the medical program, more accurate estimate

and control of costs, improved performance, better functioning of the building and

increased adaptability.

Keywords : Archi tecture; bui 1 di ng systems; design; hospital design; medical facilities;

modular design; performance; Veterans' Administration.

31
I . Obj ecti ves The objectives of the Veterans Administration (VA) study on Systems Integration--

to develop a new and improved method for the design and construction of VA Hospitals--

were five in number:

1) Cost Control - Reduction of costs was an ultimate goal but in this age of

constantly increasing costs, control of costs by knowing more positively at an earlier

point in the overall development of a project what the various costs were, and identifying how they might be adjusted, seemed to be a more feasible objective.

2) Improved Performance - It was desired to make it possible for the hospital

building to be more easily maintained. This meant a building that would give the

maintenance personnel the ability to maintain and repair equipment in an economical

way while also providing easy access to equipment and piping.

3) Adaptability - This was one of the most important objectives. Hospital

medical technology and the resultant medical facility needs, were and still are changing so rapidly that buildings just had to be more responsive to these needs for

change. Ability to "change and revise" the facility, therefore, was a very important

cri teri a - -and to be able to accomplish these changes within reasonable costs and with

as little disruption to the functioning hospital as possible.

4) Time Reduction - Traditionally, VA Hospitals have been taking from five to seven years to compl ete--thi s is from the time of project approval through program

planning, design and construction. Throughout all this time, not only were medical

needs changing, but costs were also i ncreas i ng- -s o success in time reduction would also

assist cost control.

5) Progressive Development - If any developed System would be outdated and out- moded after its first application, it would be of very limited value. Therefore, the

objective was to develop a system that could be continuously updated to accept new technological and medical advances without completely revising the system.

II. Scope

There were also certain rules that were laid down for the Consultant to follow--

the Project Scope:

1) There were six subsystems to be developed in detail: structure, partitions,

ceiling, heat i ng- vent i 1 at i ng-cool i ng (HVC), plumbing distribution and electrical distribution. Other systems throughout the hospital; such as transportation, communications,

etc. were to be considered to the extent they affected or were affected by the six

subsystems developed in detail.

2) The resultant Building System must be buildable using available components and

products. The VA did not have the authority to commit itself to any kind of guaranteed

market needed to stimulate new product development (such as the SCSD project).

32
3) The System was to apply to new construction only. Remodeling has many problems

peculiar only to that type of work and would, therefore, place unnecessary restraints on the System.

4) The System must be applicable nationwide. The VA operates hospitals in all the continental states and any future new hospital could be located anywhere in the

country

.

5) The System must be procurable within current laws and regulations. It was the desire of the VA to be able to apply the Building System without any delay that

could be caused by the necessity of revising laws or regulations in order for the

System to be legally procurable.

III. VA Systems Theory

The VA Hospital Building System is more a system of "planning and organization"

than a system of "hardware". It is not dependent on any particular component or product but provides a means for using conventional products and materials within

established modular di s c i pi i nes - -pro vi ded they also meet certain performance criteria

which have been established.

The System provides a general solution to the general problem of hospital design.

The approach, therefore, has been one of developing strategies for planning and con- struction which establish a basic compatabi 1 i ty , while at the same time, allowing wide

latitude for different project requirements, different siting conditions and different

materials most suitable to the specific problem.

The Building System is essentially composed of three parts: Data B as e- - P 1 an n i n

g

Modul es --Bui 1 di ng Subsystems.

1) Data Base - The Data Base states the "User Needs" in the form of functional,

environmental, psychological and esthetic needs. These needs are subsequently interpreted as functional and performance requirements which determine space allocation,

arrangement and environmental characteristics for the Building System.

2) Planning Modules - Planning Modules are areas of space with an assured capacity

to accommodate a wide variety of hospital activities. The modules have certain common characteristics which permit their assembly into hospitals of widely different size,

program, siting and esthetic treatment.

3) Building Subsystems - The Building Subsystems are the components of the VA Hospital Building System the parts which transform the building from planning to construction. Although the Subsystems could be thought of as the "hardware" of the

System, they are described in a general nature with a requirement to meet established

performance cri teri a--the System, therefore, is not dependent on any specific material

or component.

IV. Planning Modules

Let us now look more closely at the Planning Modules and Building S ubsys tems - -f i rs

t

the Planning Modules.

33
There are four types of Planning Modules: structural bay, service module, space

module and fire section. (Figure 1)

1) Structural Bay - The Structural Bay is the basic unit of which all other planning modules are composed. It establishes the basic dimensional disciplines for the

Building System and was developed through an in-depth evaluation of the "User Needs"

or minimum requirements for nursing units. Analysis had indicated that the nursing

unit was the most repetitive and most stable functional unit in the hospital. The

dimensions were then tested out for compatabi 1 i ty with space requirements in other

functional areas and final dimensions were established. Structural bay widths are a constant 22.5 feet (6.86 meters) throughout the hospital. Bay depths (beam spans) may

vary from a minimum of 40.5 feet (12.34 meters) to a maximum 58.5 feet (17.83 meters)

in 4.5 feet (1.37 meters) increments. Where required, an 18 foot (5.49 meters) cantilever is also available for use. These beam spans are about twice what the VA has most often been using in its hospital design. Through analysis of the complete building

as a "system" it was determined that longer spans were unnecessary and uneconomical.

The dimensions established, therefore, were determined to be the most compatible to all the requirements they must sati sfy--both from a standpoint of space planning and

structural design.

2) Service Module - The Service Module is the basic Planning Module for the

Building System. It will be one of the most important "tools" used by the Architect/

Engineer (A/E) in developing his hospital plan and building configuration. In size it may vary from 5,000 square feet (464.5 square meters) to 15,000 square feet (1393.5

square meters) the final determination being made after a comparison with space module

sizes (which we will talk about in a moment) and overall medical program space requirements ,The Service Module consists of a service bay, service zone and functional zone (Figure 2). The Service Bay provides shaft space for all the vertical ductwork, piping,

electrical conduit, busduct, etc. serving that portion of the building. It also

provides space for air conditioning (A/C) and HVC units, pumps, electrical panels and

other equipment supplying the service module. Space is also allotted for exit stairways. This allows each Service Module area of the building to be mechanically independent. This independence of the service module permits one unit to undergo alterations without affecting other areas of the hospital still in operation.

Services are fed out of the service bay into the service zone which carries all the horizontal service distribution of the service module. Within the service zone,

all service runs are organized on the basis of reserved subzones to simplify design

and installation, minimize cross-over problems and to preserve right-of-ways for future

servi ce runs . Primary subzones (Figure 3) are horizontal layers of the service zone that define

the direction of travel of the services. The main service distribution lines enter

from the service bay immediately below the beams and run parallel to the main girder

to the end of the service zone. Branches run at right angles to the mains and are located on the layers immediately above and below. Plumbing and drains occupy the

upper layer between the beams. HVC and electrical occupy the lower layer. Laterals

run at right angles to the branches and parallel to the ceiling system strongbacks

immediately above the ceiling.

34

36
All dimensions are nominal.

-center lines of beams & ceiling hangers —

BRANCH

DISTRIBUTION S2

MAIN DISTRIBUTION S3 3r

BRANCH

DISTRIBUTION S4

lATERAL DISTRIBUTION Ss

live supply and exhaust plumbing

electrical

Figure 3

37
The direction and depth of beams, girders and ceiling strongbacks visually locate

the respective layers and provide physical references in the service zone both for the

initial location of services and for later revisions of the layout.

Secondary subzones are vertical divisions of the main distribution primary zone

for particular services and are defined by the ceiling hanger spacing.

The functional zone portion of the service module houses the functional areas of

the hospital, and can be internally organized in various ways to accommodate different

functions. All services downfeed into the functional zone from the service zone above

with the exception of the gravity drains which drop to the service zone below.

3) Space Module - The Space Module is a sub-unit of the service module and is the planning module used in the patient care areas--or Nursing Unit. The internal

organization is more precisely detailed than the service module, taking into account

the special requirements of these areas such as exterior exposure at the building

perimeter. There are a total of eleven modules available which vary in size from a minimum of approximately 3,000 square feet (278.7 square meters) to a maximum of about

10,500 square feet (975.5 square meters). Each has been tested and determined to provide the required space for a nursing unit and its related functions relative to different medical program requirements. They have also been tested for other specialized

functions such as Psychiatric Nursing Units, Research Lab's and Intensive Care Units

(ICU's). Final selection of the space module to be utilized in a design problem is made after relating the medical program space requirements for the hospital under design

to the space modules. A cros s -compa r i s on is also made with service module sizes to determine their suitability to satisfy the requirements of the remaining portions of the

hospital. When a satisfactory correlation has been achieved, both the space module and

service module size are set.

In utilizing space modules for the planning of Nursing Units, the A/E may sometimes

find he does not have sufficient space to accommodate all the services that are necessary

to the Units being planned. When this happens, the A/E can add "Additional Space" to the space modules in increments of one bay width (22.5 feet - 6.86 meters). In effect,

this area becomes a "connector" between space modules or service modules. Consideration

of the need for this space is made, of course, during the analysis of service modules

and space modules just di s cus s ed--and if it is determined the space is needed it then

becomes an "extension" of the space module and a "part" of the service module. In discussion this may sound crude and one might say from the standpoint of size there are really no space modules or service modules--but what this feature really does is permit

the designer to "custom fit" the System to the specific space requirements of the

design problem and it becomes, therefore, a tremendous design asset. What happens in actual practice, then, is the A/E analyzes the building space

requirements relative to the available sizes of space modules, service modules and

additional space and selects for use in his design the one, or ones, which best satisfy

al 1 the requi rements .

4) Fire Section - There is one additional rule the designer must keep in mind while

determining the service module size. Code requirements do not allow hospital buildings

to have areas larger than 20,000 square feet (1858.0 square meters) without suitable

two-hour fire separation. Just as the space module is a sub-unit of the service modulelikewise the service module is a sub-unit of a Fire Section. The goal, therefore, is to

38
have the boundaries of one or two service modules coincide with the boundary of a fire

section; keeping in mind the code limitation of 20,000 square feet (1858.0 square meters).

As any penetration of a two-hour fire wall must be properly protected, the coincidence of service module and Fire Section boundaries greatly minimizes the number and

complexity of service penetrations. With the two-hour fire walls also being the only

partitions which are installed s 1 ab -to- s 1 ab , it can be seen that a complete "box" is formed which is both an independent fire section and (mechanical) service module within

the total building. Operationally, it is like many little buildings placed together to form the total building and it is hoped the System will provide fire sections of a much more regular shape and outline than in the past.

V. Building Subsystems

We have discussed the Planning Modules used to develop the building plan--now let

us look at the Building Subsystems which go together to create the form of the building.

The Subsystems are divided into two categories; shell and service (Figures 4 and 5).

The shell subsystems are composed of structure, ceiling and partitions; service subsystems

are composed of the HVC system, plumbing distribution system and electrical distribution

system.

Each subsystem is developed as a general solution to a general design problem; that

is it provides a range of options for appropriate selection and application to a specific

design problem, each option having different space, performance or cost characteristics.

Within this context, specific materials are not dictated by the System, only their

performance. The project A/E will then select the materials best suited for the particular job and location. .

1) Structure - The basic structural system is a column, girder and beam assembly

with shear walls or braced frames assuming lateral loads. A three inch (7.62 centimeters)

topping slab completes the system and allows for flexibility and adaptability of floor

finish application. Material options are steel, precast or poured- i n -p 1 ace concrete.

The organization of the structural components remains the same regardless of the material

used. The top of the perimeter girder is level with the top of the beams. The top of

interior girders, however, are flush with the bottom of the beams. This permits the

passage of plumbing utility lines over the girders between the beams. Beam spacing is modular throughout the building but it will vary depending on material used--if the

material is concrete the spacing is 4 feet - 6 inches (1.37 meters); for steel the

spacing is 5 feet - 7h inches (1.71 meters). Both of these dimensions are compatible

with the 22 feet - 6 inch (6.86 meters) standard bay width.

There are two uniform loadings considered throughout the building--75 pounds per square foot (366.2 kilograms/square meter) in the patient (Nursing Unit) areas of the

hospital and 115 pounds per square foot (561.4 kilograms/square meter) in the support

areas of the hospital. Beam, girder and column dimensions are not set but minimums and

maximums are established which are compatible with other system rules and are sufficient

to carry the established loadings.

2) Ceiling - The ceiling system is probably the most unique of all the subsystems

developed within the Building System. It is a load-bearing walk-on platform which

serves as a working platform for the service zone (interstitial space) with the finish

39
40
41
ceiling treatment applied to the underside of the platform. It provides support for and

is the terminus for partitions as well as contributing to fire safety. As previously

mentioned, the only partitions that extend from slab to slab and penetrate the ceiling

are fire walls. The ceiling also acts as an acoustic, thermal and aseptic barrier

between the functional and service zones.

The ceiling platform may be constructed from any acceptable material that will

provide for the required 40 pounds per square foot (195.3 kilograms/square meter) live

loading. The platform is supported by a framework huna from the structural system above

by adjustable hanger rods, giving it the capability of fine level adjustment for instal- i lation of the ceiling finish to the underside surface. Surface mounted lighting is utilized to limit penetration of the platform--if recessed lightinq is required in some j area, however, provision is made for suspended ceilings. The Building System is not dependent on a fire rating for the ceiling as semb ly--f i re rating reqirements will be determined for each individual project. At this time there are no available ceiling

assemblies with established fire ratings. However, the VA Hospital Building System was applied to a private community hospital in California by the consultants who developed

the System for the VA--in this project a poured-i n-pl ace aypsum deck was used for the

ceiling platform material and when the assembly was tested, it exceeded the requirements

for the two-hour test.

3) Partitions - Partitions are basically divided into two categories; rated and

non-rated. Rated partitions are the two-hour fire partitions which extend from slab to slab and serve to enclose fire sections. Non-rated partitions include the one-hour

smoke tight corridor partitions and partitions separating rooms. Materials and finishes

may be those best suited to the functional area where located and the most cost effective

for the geographical location of the project--the main criteria being that they meet the

performance requirements established and are easily relocatable.

Partitions are uniform in height for any service module and generally are 9 feet

(2,74 meters) high in nursing unit areas and 10 feet (3.05 meters) high in support service

areas of the hospital. With all partitions (except fire walls) stopping at the ceiling,

a tremendous advantage is gained in the service zone with no partitions or studs to interfere]

with the service lines. It also greatly simplifies the fire stopping problem as well

as allowing establishment of uniform methods of attachment and lateral support and for

acoustical seal around the partition perimeter.

It is recommended that, wherever possible, all services remain outside the

partition and be contained in service containers. This feature, along with the fact that

there is a complete separation between the functional and service zones, allows for

simultaneous installation of partitions and services. It should also greatly simplify

future maintenance and remodeling.

4) Heati ng- Ven ti 1 ati ng-Cool i ng (HVC) - The first service subsystem we will discuss

is the heati ng- ven ti 1 ati ng - cool i ng system; many times referred to simply as the HVC system. The basic design offers two alternatives, a 1 ow-or-medi um-pressure terminal

reheat system or a dual-duct mixing-box system, and must be capable of providing from

25 to ICQ percent outside air.

Fan units, pumps, etc. are located in the service bay along with all vertical ducts.

Heating and cooling generating equipment may be remotely located or complete package

units may be located in the service bay. Ductwork feeds out from the equipment into the

42
service zone where distribution is made to the functional zone bel ow in the organized

fashion as previously di s cussed--wi th one of the main points to remember that each time

a service line changes direction, it also changes elevation.

5) Plumbing Distribution - The general organizational pattern for the plumbing

distribution system is the same as for the HVC system--all vertical risers and any necessary equipment are located in the service bay with horizontal distribution occurring in the service zone and then downfed to the functional zone below. The one exception to this is the gravity drains which drop into the service zone from the functional

zone above.

Conventional materials and assembly procedures are used but it is expected that a greater quantity of material will be required. This will be offset by the easier

accessibility for maintenance purposes, which makes it more economical, and an expected

lesser cost for remodeling changes.

6) Electrical Distribution - As with the HVC and plumbing distribution systems,

electrical distribution is also accomplished by the same highly organized pattern of

distribution layout. All necessary transformers, electric panels, etc. for a service

module are located in an electrical closet in the service bay with electric feeders

going out into the service zone for distribution down to the functional zone below.

There is one additional characteristic of the building s ubsys terns -- certa i n of the

components are designated "permanent" and others "adaptable". The components which are labeled permanent are considered, theoretically, to never require change throughout the

life of the building; in other words their modification or removal would require major

building reconstruction. Components falling into this category are all the structural

system except for the topping slab, all the ceiling system except the ceiling finish,

the two-hour fire wall partitions of the partition system and all the main trunk ducts

and main service lines of the HVC, plumbing and electrical distribution systems. All other components are considered adaptable and are assumed to be subject to change and

alteration on a random basis throughout the life of the bu i 1 d i ng - - they can be relocated,

altered, added or deleted without major building reconstruction.

VI. Conclusion

It is felt there can be many advantages in using the Building System:

1) A better response to medical program requirements is possible. With the

possibility of overall project time reduction and the capability to analyze many

functional relationships through use of the planning modules; medical program

response should be better.

2) The Planning Modules and Building Subsystems should allow for a more accurate

estimate and control of costs.

3) Building performance should be improved by the highly organized layout of

service distribution and easier accessibility to mechanical equipment and piping.

43
4) Function of the building should also be improved through the planning

capabilities available from the planning module concept of design.

5) Last--and probably most important--the adaptability potential of the building

should be vastly increased. Division of the building into independent service modules

each containing its own service bay, the service distribution concept, a load-bearing

ceiling completely separating functional and service zones, partitions which stop at the ceiling and contain only a minimum of utilities, and the permanent and adaptable

components concept--all are characteristics which should increase the adaptability

capabilities of VA Hospitals when designed by application of the VA Hospital Building

System

.

44
NATIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Ga i the rs b u r g , Md. (Issued July 1 974)

INTRODUCTION - Current Issues in Health Care Facility Delivery

Donald D. Boyle

Chief, Development Division

Facilities Engineering and Construction Agency

Department of Health, Education and Welfare

ABSTRACT Some of the issues of concern to Health Care Facility Delivery are better

planning, better prediction of facility needs, improved sensitivity to the need for

responsive facilities, containment of parochial attitudes, restatement of the emphasis

in planning and design and improvement of the management process. Failures in this area include lack of consideration of life cycle cost, non-utilization of available

management and procedural skills and the numerous Federal, regional. State and local

building and life safety codes that hamper technological advances. In a recent report

to Congress, the General Accounting Office (GAO) identified these items and others and

provided detailed recommendations. The Facilities Engineering and Construction Agency

(FECA) presently has three projects dealing with these issues and problems. These

projects include the investigation of the design process, the construction of three

office buildings to performance specifications and using new management concepts and

the third is the construction of five Indian Health Service hospitals using a sophisticated management plan.

Keywords : Architecture; construction; design; hospital design; management; medical

facilities; performance specifications.

45
I was much impressed by the two previous presentations by DoD and the VA. We will

follow the applications of those concepts with great interest, and it is reassuring to see so much effort expended in improving design and construction methods and techniques.

We should remind ourselves frequently, however--say every mo rn i ng -- that there is a fundamental issue behind all this, which is to plan and design with more responsiveness

and sensitivity to the needs of both the patient and the practitioner.

There is a pot pourri of issues--we could take a sounding and probably not get the

top 20 in the same order on any two people's lists, but these are some of the issues

which concern me, and which I believe concern many of us, at this point in time:

0 To plan better so that facilities are on line when needed.

0 To predict facility needs five to ten years ahead to permit intelligent

development efforts.

0 To improve our sensitivity to the need for facilities which can respond

to the inevitable changes in health care delivery.

0 To contain parochial a tt i tu des - -we all enjoy a few--which are not consistent

with our common cause.

0 To re-state the emphasis in planning and design of facilities so that the

needs and the facility responses to those needs are much more rigorously

tested during the conceptual effort .

0 To improve the management process on facilities procurement.

Perhaps at this moment the other side of the coin would be worth exploring, the

negative side.

It gives us a feeling for the magnitude of our problems when we recognize that,

even with the impressive advances which have been made, we still are not responding

adequately, across the broad spectrum of health facilities, to the environment in which we work.

It's a tough environment;

0 Simultaneous escalation and tight funding;

0 Changing needs;

0 Split responsibilities and conflicting requirements for similar work; and

0 A downward trend in staffing.

We can't wrestle with all of our problems here, but let me touch on three:

1) Our failure, our long-standing failure, to consider facilities cost in true perspecti ve--that is, in the light of the total life cost of the facility and

all that goes on within it. We have the understanding and the skills to do so, but

we have a lot of inertia to overcome.

Why is it so important? Because the early deci s i ons --t hos e which define the

concept--shape the bu i 1 di ng --de term i ne the response to the functional requi rements -- can have a dramatic effect on the total life cost--operations , alterations, and

so on. But we persist, even today, for the most part, in viewing a construction job

as an entity unto itself.

2) Our failure to utilize the management and procedural skills available to us--this costs us money --and it costs us time. When time and expenses go up on a given project and within a given budget-- qual i ty has no place to go but down . Technologically, I have no argument with anyone. As needs are perceived, designers,

fabricators, manufacturers, and builders respond beautifully. What then am I talking

about?

46
The Tools

0 Phased design and construction;

0 Pre-bidding;

0 Performance specifications;

0 Others.

Certainly there are constraints to the use of these tools.

0 The law, in some cases;

0 Funding patterns, sometimes;

0 Regulations, on occasion;

0 Habit.

Whatever the constraint, there are ways to overcome it, including, when necessary,

proposing corrective legislation.

Constraints or no, time marches on, and at this point we have only two choices:

Lead the march;

or Watch it wal k over us

.

This may sound like a pretty harsh indictment of the Federal camp. Perhaps we deserve a harsh indictment.

3) As problems go, the quagmire of Federal, regional, State, and local building

and life saftey codes and regulations certainly hold an important place in terms of

hampering our ability to take advantage of technological advances.

Despite these three problems, I do not mean to imply that we have not made progress

on the issues which I outlined earlier. However, I do suggest that we have been

progressing at a snail's pace. How could we afford such a luxury?

Nobody had ever put the monkey on our backsl

Sombody just did;

The General Accounting Office (GAO) report to the Congress of November 20, 1972,

on their "Study of Health Facilities Construction Costs" did just that.

For those of you who haven't yet studied the GAO report, I will paraphrase six

recommendations which relate to this topic. There are many others, all of great

1 nterest

.

GAO Recommendations (Paraphrased)

0 That the Department of Health, Education and Welfare (DHEW), assisted by

the American Institute of Architects and the American Association of

Hospital Consultants, publish essential factors to consider in the functional planning process--and the methodology to be used.

0 That DHEW explore reuse of designs from one facility to another and, if appropriate, establish the criteria under which designs, or elements of

designs, could be reused.

0 That DHEW adopt a common set of requirements for new construction under

Hill-Burton, Medicaid, Medicare.

0 That DHEW work with the National Bureau of Standards (NBS) to develop a scientific base of knowledge on lifefire safety. We see this as $500,000

per year for 5 years--we would hope for full participation by many Federal

agencies. A relatively small effort is already underway.

47
0 That DHEW participate heavily with NBS and others to improve our health

facilities construction requirements and cooperate with model code groups

and states.

0 That DHEW issue policy guidance on the use of both phased design and

construction and the total concept approach. In addition, that their use

be considered on all projects assisted under the Public Health Service

Act

.

We have presented some of the critical issues of today, some related problems,

and some very important recommendations by the GAO

.

Now I should like to mention three on-going projects in which FECA is a participant and which come to grips with some of those issues and problems.

The first is a contract with a joint venture--Perki ns and Will; Cresap, McCormick

and Paget; and McKee, Berger and Mansueto, to evaluate the processes through which

health facilities are procured under the grant and loan programs of DHEW. The contract

will be completed in February. In the course of evaluation, these are the basic

thrusts

0 To improve on the process itself; the interfaces, the timing, consistency

between programs, elimination of unnecessary constraints, and faster testing

and assimilation of new concepts, both technical and managerial.

0 To improve on the gathering and use of data, and on the concepts and

procedures contributing to life cost analysis and related decision

making.

The second is a project with General Services Administration (GSA) and Social

Security Administration (SSA) to build three Social Security Administration Payment

Centers in three cities. That is approximately $100 million in construction having

nothing to do with health facilities. However, these facilities bear watching, since

they provide an excellent test bed for three of the tools which we can use in health

facilities construction:

0 The Executive Arch i tect/ Engi neer (A/E) function;

0 The Construction Manager concept, and;

0 Performance specifications.

The third project takes full cognizance of the fact that it is during the planning

and conceptual development that we can have the greatest impact. In that period the

deci s i on s are made which pretty well determine how well the project is going to respond

to the user's needs.

Joseph Russo has been guiding a project through that stage of development. He will

tell you now about how that project demonstrates a somewhat sophisticated management

plan and uses the tools which we have mentioned earlier. The project will procure for

the Indian Health Service, five hospitals across the Southwest.

48
HAIIONAL BUREAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5 , 1 972 , Ga i ther sburg , Md. (Issued July 1 974 )

Application - Current Issues in Health Care Facility Design

Joseph D. Russo Architect/Planner

Facilities Ennineerinq and Construction Aoency

Department of Health, Education and Welfare

ABSTRACT The Facilities Enaineerinn and Construction Aoency (FECA) is presently

accompl i s hi nn a project for the delivery of five health facilities. Unlike conventional

projects, FECA commissioned an Executive Archi tect/Enqi neer (A/E) to review the programs

of requirements, develop a functional definitive design kit upon which schematics would

be based and to oversee the work of five regional A/E's who would be responsible for

final design. Other unique aspects of this project include the use of a flexible

management system, the use of a functional definitive desian kit, the reguirement for a guaranteed maximum price early in the design process from the construction manager and

other innovations. Benefits include better quality Health Facilities delivered in shorter time and at a lower cost than through traditional means and the basis for

continuous improvements of future health care facilities.

Keywords : Architecture; buildino systems; construction management; desinn; hospital

design; medical facilities; performance; planninn; nronramminn.

49
You have heard Mr. Boyle discuss the issues with which we are concerned in the

overall business of delivery of health care facilities. I should like to point out that,

depending on the particular point in the building process, the issues have different

degrees of influence. In Figure 1 is indicated the degree of influence o-^ decisionmaking at various points along the project path. If the chart were continued, we would

probably work our way up to the highest levels of government. In other words, the chart

represents the big picture. It's in these earlier stages where the degree of influence

is the greatest and where most of the work needs to be done. Whether we call these

stages "comprehensive health planning" (for definitions see Appendix A) or call them

"improvement of a national health care delivery system" (including social, physical,

economic, and management planning), they represent all the decision making which happens

earlier and impacts on the delivery of health care facilities.

As important and interesting as these earlier issues may be, they will not constitute the theme of my talk. As an architect, my area of involvement tends to start during the programming stages of the process. Consequently, I should like to focus on

a specific project during the facilities "delivery stage which addresses the issues and

incorporates the tools or management concepts mentioned by Mr. Boyle.

It happens that this project was well along when the General Accounting Office

(GAO) study was undertaken and we are delighted that their recommendations reinforce the

thrust of our project.

The name of the project is: IH5/FECA Management System Health Facilities Project.

This project is being accomplished for the Indian Health Service (INS) by FECA. The total project will involve the design and construction of five health facilities

to meet the health needs of the Indian communities and to provide adequate resources for

provision of a comprehensive, curative, and preventive health care program.

Very early in the programming stages of the project it was decided to design a management system to serve as the conceptual framework or backbone upon which we could

build over a period of time.

The general management system involves a Government team and a builder team. The

builder team consists of an Executive Archi tect/ Engi neer (A/E), Regional A/E's and

Regional Construction Managers (C/M's). The Government will furnish, to the Executive

A/E, five program of requirement documents which define the scope, health care programs,

staffing patterns, workloads, budget, and other data for the five health facilities

projects. These program of requirement documents are intended to serve as user requirement material for the project. The Executive A/E will review these five documents and may propose changes to the technical requirements. Based on these five program of

requirement documents and contact with the users of each facility, the Executive A/E

will then develop five separate study drawings. After approval of these drawings has

been given a functional definitive design kit will then be developed from the drawings,

as well as an analysis of the common requirements of the five health facilities (i.e.,

architectural, structural, mechanical, electrical, functional relationships, modularity

requirements, building mass, etc.).

In addition to basing the functional definitive design kit on an analysis of the

five design criteria documents and the five study drawings, the Executive A/E must

consider and reflect the five-year IHS hospital construction program, IHS national

health care delivery system, and IHS medical philosophies. Such program information

will be provided to the Executive A/E by means of a one- or two-day seminar which will

50
THE COST OF WRONG DECISIONS

SEQUENCE OF DECISIONS

Figure 1

51
include handout material. The functional definitive desiqn kit will serve as the main

input into the Executive A/E's further development of schematic documents for the

five facilities, with local conditions finally determininn each schematic. The study

and schematic documents will then be made available to Reoional A/E's for further

devel opment

.

The Executive A/E services will be performed under the direction of the Government's Project Manaqer (PM). The Executive A/E will also be retained durinq the

regional desiqn and construction phases to coordinate the total desiqn effort and to assist the Government where necessary to resolve problems that may arise. As a means

of insurinq accountability of the Executive A/E's effort, the Executive A/E will serve

as Reqional A/E for one of the five projects. In this dual capacity, he will obviously

proqram his total work in a manner which minimizes overlap of effort and maximizes the

qual i ty of effort

.

The Reqional A/E's will each be responsible for the completion of a specific

project, utilizing the study and schematic documents provided by the Executive A/E.

The Regional A/E services will be performed under the conceptual guidance of the

ExecutiveA/E.

The project contains several management concepts that have been tried on an individual basis elsewhere, however, it is one of the few projects whose sponsors have

consciously attempted to incorporate the advanced state-of-the-art in building technology.

Such an attempt has resulted in the integration of all of the following management

concepts in one package:

1. Executive A/E

2. Reqional A/E's

3. Regional C/M's

4. Phased Design and Construction

5. Construction Management

6. Building Systems

7. Bulk Buying

8. Value Engineering and Life-Cycle Costing

9. Performance Specifications

An additional ingredient in the project is the use of a functional definitive design

kit. In fact, we hope the kit will be the avenue by which we will incorporate the other

management concepts.

In summary, the project utilizes a management system which emphasizes flexibility

in management. This approach is a counterpart to the idea of flexibility in building

hardware. In short, keep all options open and don't make a decision until you have to; but when it's needed, make it and make it expeditiously.

An outline of my talk is as follows:

1 . Why the project?

2. Objectives

3. Management-System

4. Documentation

5. Benefits to Indian community, IHS, and FECA

6. Benefits to the Department of Health, Education and Welfare (DWEW)

52
1 . Why the project ? a. Health Facilities are needed.

b. To respond to the President's message to Congress and follov/-up attitude

of House and Senate.

2 . Obj ecti ves The objectives of this project are as follows:

a. To provide health facilities which respond to the health needs of

American Indians.

b. To maintain or improve facility quality.

c. To reduce project time.

d. To reduce project cost.

3 . Manage me nt-Sys tern To best meet the objectives noted above, we decided to develop the

management system mentioned earlier which is primarily concerned

with the total design and construction process. The first task

prescribed is to identify, isolate and take advantage of the common denominators in each project. We feel our approach can provide better supervision of projects. Also it can provide lower

expenditure of Government manpower resources by having a single

A/E coordinate the work of several additional A/E's.

Figure 2 represents the conceptual framework for the project. It's essentially a generalized process diagram indicating the activities

of each participant over time.

In addition to the most obvious elements of the management system,

some of the more hidden elements include the use of concepts

inherent in the ABS project, and the Florida SSP projects and the use of post evaluation and feedback. The point in the process to request a guaranteed maximum price (GMP) is a variable deserving

of much evaluation as the project develops. In some situations,

the GMP can be solicited early, while in other situations the GMP must be solicited later. The prudent project manager should allow

a contingency fund in his fiscal spending plan to "buy more design"

if the situation demands it. On one project the correct time might

be at the end of preliminaries, while in another case that stage

may be too soon; therefore, the GMP solicitation should be postponed

to the end of intermediates or later stages.

Figure 3 shows, in general terms, how the Executive A/E might approach

the issue of common users' requirements for each project.

Figure 4 summarizes the various management concepts which form a part of the project and indicates in which phase of work each concept

is to be appl i ed

.

53
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54
TASKS

PARTICIPANT^

TASKS

CONVENTIONAL

PROCESS

TASKS

IHS/FECA

MANAGEMENT- SYSTEM

EXECUTIVE

A/E

Executive Architect/Engineer (A/E) Does Not Exist

Architectural, Structural, Mechanical, Electrical and Other Requirements;

Functional Relationships;

Massing and Module Requirements and Others

REGIONAL

A/E-C/M TEAM

Architectural, Structural, Mechanical, Electrical and Other Requirements;

Functional Relationships;

Massing and Module Requirements and Others Program of Activities and Cultural Requirements

Program of Activity Requirements

(e.g. surgery, radiology, etc.). Cultural Requirements

REGIONAL

A/E-C/M TEAM

2

REGIONAL

A/E-C/M TEAM

3

REGIONAL

A/E-C/M TEAM

4

REGIONAL

A/E-C/M TEAM

5

Figure 3

55
SUMMARY

"""""^^^ APPLIED LUNLbrlo ^""x.^^ I n nia

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55
Figure 5 represents a traditional functional definitive and can be found

in use in many offices. While this type of definitive may have merit,

it is not what we are looking for. We are seeking a functional definitive

design kit as shown in Figure 6, a kit possessing the capability of achieving

all of the characteristics of the traditional functional definitive. The

outstanding feature of the kit will be its flexible and adaptable building

block elements. We feel that these flexible and adaptable elements will

permit the designers to deal with the different external site-related forces

and internal bu i 1 d i n

g -re 1 ated forces, both of which generally shape the

building 1 ayou t

.

The final ingredient necessary to make the project work is a total team communication system as shown in Figure 7.

Documentati on The following documentation is necessary for this project:

a. Preliminary analysis of common features of five health facilities.

b. Government management plan.

c. Executive A/E contract.

d. Regional A/E contract.

e. Five Program of Requirements documents.

f. Project spending plan.

Benefits to Indian Community, IHS, and FECA

The benefits to the Indian Community, IHS and to FECA will include:

a. The management system will deliver five hospitals of better quality,

in shorter time, and at lower cost than can be delivered by the

traditional one-by=one approach.

b. It will provide a model for IHS, both for delivery of projects

and for obtaining funding.

c. It will provide a basis for continued improvement of future

f a c i 1 i t i e s .

Benefits to PHEW Finally, the results will be available for application to other DHEW Federally assisted programs.

57
4

TRADITIONAL FUNCTIONAL

DEFINITIVE (SCHEMATIC)

Figure 5

58
59
COMMUNITY

INDIAN HEALTH SERVICE (FIELD) INDIAN HEALTH SERVICE (WASH.) DIRECT TEAM COORDINATION S INFORMATION

INDIRECT TEAM COORDINATION a INFORMATION

COMM.=

IHSF = IHSW =

60
Appendix A

DEFINITIONS

1. Building System Refers to building "parts," with rules

governing their manner of composition

to achieve some needed level of performance. An example of a building system

would be Habitat at Expo '67.

2. Comprehensive Planning Overall pre-design planning (including

social, physical, economic and management planning) to accommodate the short

and long-range objectives of a particular health care, educational, or welfare

program, with emphasis on integrating

the program within the community it is intended to serve. Inherent in comprehensive planning is a systematic approach

to obtaining optimum consideration of

broad user needs and thus providing

facilities responsive to these needs.

3. Functional Definitive Design Kit A kit including design elements with rules

governing each element's use. Each element

could involve one room or more or up to one department or more. The design kit must

have the capability of achieving all of the

above characteristics noted in the traditional functional definitive. The design

kit differs from the traditional functional

definitive in that it is made up of flexible

and adaptable elements.

4. Guaranteed Maximum Price CGMP) A price offered to the Government prior to the start of construction for completion

of the project. Guaranteed maximum priced

contracts guarantee that the reimbursement

for the cost of the work, as set forth in the contract documents, will not exceed a stipulated sum. The Construction Manager

(C/M) shall provide performance and payment

bonds each in the amount of 100 percent of

the Guaranteed Maximum Price. In the event

that the cost of work as set forth exceeds

the stipulated sum, the Construction Manager

agrees to complete the work at no additional

cost to the Owner. The ultimate cost of

work to the Owner shall be calculated on the

basis of the summation of all contracts

awarded, the cost of materials purchased

and the cost of reimbursable items

authorized by the Owner in executing the

work. Any savings realized through the

reduction in the cost of the work below

the stipulated Guaranteed Maximum Price accrues to the Owner.

61
5 . Life-Cycle Costing A concept of considering total costs which

include:

a. initial costs;

b. program costs during project delivery;

c. progran operations cost after project

deli very

;

d. financing costs;

e. building operations costs;

f. maintenance and repair costs and

g. alterations and replacement costs.

In addition, the salvageabilitv or final

value should also be taken into account

when considerina total costs.

6 . Program of Requirements A document which defines the project in terms of people, pronrams, and facility

related needs. Also, the interrelationships

amonn these needs. It is the result of

information developed durinq the comprehensive planning phase. Site selection and

site utilization analysis reports, user needs, health care services, space allocations, special relationships, staffing

patterns, etc. are included. A well

prepared document enables an architect to design a building or group of buildings

with minimal additional guidance. The

document serves as a deterrent to unnecessary modifications or increases in the

scope of a project.

7. Post Evaluation The critical i n ves ti oa t i on and measure

of response of the facility to its

intended and/or present use. Closely

related to evaluation is the feeding back

of the results in the loop of information

which controls decision makinq.

8 . Regional Construction Manager (C/M) The individual who is oenerally responsible

for providing a construction concept during

the design stages and a guaranteed maximum

price, and later is responsible for implementing construction. In the early stages

of the project, his expertise will be

primarily provided to the Executive A/E.

After approval of schematics, the Regional

C/M's expertise will shift emphasis and be

primarily directed to the Regional A/E.

9 . Systems Building

10. Traditional Functional Definitive

The "how" of project delivery.

A single line drawing generally considered

to be a schematic and showing or enabling

the following:

plans, elevations, sections, etc. square foot allocations for various

functions

configuration of building with structural system

pricing of facility

utility requirements (e.g., power, water,

heat, A/C, etc.)

equipment layouts

special considerations (minimum head room, critical dimensions, etc.)

62
NATIONAL BUKLAU OF STANDARDS BUILDING SCIENCE SERIES 54, Proceedings of the

First Federal Agency Workshop, December 5, 1972, Gaithersburg, Md. (Issued July 1974)

An Evaluation Methodology for Hospital Nursing Units

Robert Wehrl

i

Chief, Architectural Research Section

Technical Evaluation and Application Division

Center for Building Technology, lAT National Bureau of Standards

Department of Commerce

ABSTRACT Hospital planners and designers are facing the twin trends of greater construction costs and greater demand to access to the health care delivery systems. Because of

these twin trends, these planners and designers must become increasingly aware of the

various requirements involved in nursing units. One method of achieving this is through

evaluation. The evaluation methodology that was developed by the Architectural Research

Section relies on the research aids of architectural psychology, building systems and the

performance approach. In this methodology, requirements are systematically identified

and schematic drawings of nursing units are weighted and rated based on these requirements. When allied with costs, this methodology permits a comparison of various schemes

on a performance-cost basis. It also aids the designer in improving his design of

nursing units.

Keywords : Architecture; design; evaluation; hospitals; medical facilities; nursing units

63
BACKGROUND

Today we are faced with rapidly increasing costs of hospital construction, the

primary facility in the health care system. In today's presentations, we have heard

of several Federal hospitals either under design or construction that will cost in excess

of one hundred million dollars. Concurrent with this trend of more expensive hospital

construction is the trend of more people wanting increased access to the health care delivery system. With the twin trends of increasing cost and increasing citizen demand

for access, hospital planners and designers must become increasingly aware of the various

requirements that they must satisfy in any new medical facility. It is only through an increasing awareness of these various requirements, that improved, more effective, more efficient hospitals can result. One step toward developing such an awareness is through

the design methodology which permits the evaluation of alternative design schemes in meeting these requirements prior to hospital construction. The Architectural Research

Section has recently developed such an evaluation methodology for the Health Services

and Mental Health Administration of the Department of Health, Education and Welfare.

This evaluation methodology can be used for the evaluation of hospital nursing units.

Hospital nursing units tend to be quite complex organizations for the planner and

the designer. In designing these units, they must take into account and design for such

requirements as safety, security, convenience, and efficiency. Many of these requirements are in conflict among themselves and with others, resulting in the need for tradeoffs among alternative requirements. Finally, the planning and design functions must

usually be accomplished within an extremely tight budget. To develop an evaluation

methodology which reflects this complex situation, it is useful to employ three research

approaches; architectural psychology; building systems and the performance approach.

These three are discussed as follows:

Architectural psychology is a relatively new discipline. A mixture of

behavioral sciences and architecture, it allows us to apply the results from

behavioral science research to such rooms and spaces as nursing units.

Because of the reliance on behavioral science studies, architectural psychology

allows us to focus on the psychological, physiological and social needs of

the patients and staff. The results of these behavioral studies provide us with

a rigorous aid in approaching the problem of nursing unit evaluation by focusing

on the needs of the patients and staff.

The second research approach utilized was the building systems concept.

The building systems concept provides a mechanism for considering a given

building, such as a hospital, as a system which can be analyzed into a number

of subsystems. A list of hospital subsystems would include site, structure,

enclosure, space use, transport systems, environmental systems, power distribution

systems, communications systems, and equipment. The building systems concept also

allows us to categorize the great number of requirements that the planner and designer must deal with by means of performance attributes. A performance attribute

can best be described as a collection of requirements associated with a building,

or a nursing unit. A list of performance attributes would include fire safety,

physical safety, chemi cal -bi o 1 og i ca 1 -radi ol og i cal safety, electrical safety, internal convenience and efficiency, external convenience and efficiency, anthropometric fit, physiological, social and psychological comfort, durability, reliability.

64
fit, physiological, social and psychological comfort, durability, reliability,

control abi 1 i ty , flexibility, and maintainability. The building systems concept

also allows us to list those properties that can be measured. Such a list would

include dimension, location, area, volume, mass, surface color, texture and

others. The utility of these categories, or lists, lies in their value for the

systemmatic development and consideration of requirements for hospital nursing

units, as will be shown in later pages.

The final technique utilized in developing the evaluation methodology was

the performance approach. The performance approach is an emerging technique

for developing and stating building requirements. It emphasizes the need for

rigorous and detailed studies of user requirements in buildings. In stating

building requirements, the performance approach consists of the translation of user needs into performance statements that are non -s peci fy i ng in nature. That is, a performance statement is worded so that materials, dimensions, and

specific design solutions are not included. To do this, a performance statement has three essential parts; the requirement, the criterion and the test. The requirement is the qualitative portion and the criterion the quantitative

portion of the performance statement. In the case of illumination, for example,

the requirement would state, "Adequate illumination will be provided...," the

criterion would state, "Fifty foot candles of light will..." The third part of

the performance statement is the test. The test gives the details on how a given specimen will be tested to see if it meets the stated criterion. For our example of illumination, a test would state, "lES Handbook test number..."

DEVELOPMENT OF THE EVALUATION METHODOLOGY

These three research approaches, architectural psychology, building systems and

the performance approach, have been successfully used in building research before. For example, architectural psychology has been used for determining space arrangements,

building systems have been used in the planning, design and construction of schools and

other building types, and the performance approach has been successfully applied to the

specifications for housing and office buildings. However, the three have never been

collectively utilized for the purposes of building evaluation. In developing an evaluation methodology for hospital nursing units we employed these approaches in the following manner.

First, from building systems we adopted the previously mentioned list of building

subsystems. Since we were concerned primarily with the hospital nursing unit, a portion

of the overall building, we deleted the building subsystem "site" as extraneous to our immediate evaluation needs. Likewise, we also deleted the building subsystem "structure"

as this subsystem is of primary interest in the evalution of the building as a whole

rather than one department of that building. From building systems, we also adopted

the list of performance attributes; that is, the list of what we think a building

ought to do. We then arranged these two lists of building subsystems and performance

attributes at right angles to form the matrix shown in Figure 1.

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This matrix provides us with a number of advantages in the evaluation of nursing

units, which have a very large number of requirements. The matrix shown in Figure 1 aids us in breaking down this big pool of requirements into smaller groups that are easier to analyze and evaluate. This point will be developed later. Another advantage

of the matrix is that subdividing the large pool of requirements allows researchers to examine small portions of the pool, thereby making possible the close scrutiny required.

This analytic method will become evident as we continue this approach to nursing unit

evaluation. Finally, the matrix allows us to index a great amount of information and

data in a reasonable and orderly manner. For example, we can use this matrix to organize

the extensive literature concerning the planning and design of nursing units.

After establishing the matrix, performance requirements for nursing units were developed by examining each intercept of the matrix. For example, in the intercept of the building subsystem, "Environmental System", and the performance attribute,

"Physiological Comfort", the need for such performance requirements as "Provide conditioned air," "Provide appropriate levels of temperature and humidity," and others became

readily apparent. The initial list or pool of performance requirements were developed

by a physiologist who brought to this task, experience in interdisciplinary research

from similar projects. This initial list of performance requirements was reviewed and

revised by a physician, an architect, an architect/engineer, an architectural psychologist and a medical systems analyst. The first three individuals were hospital consultants with numerous years of private practice in the planning, design and construction

of medical facilities. The other specialists brought the perspective of the user to bear on the problem.

The final list of performance requirements was very large, over 150 such requirements being so identified. This well illustrates the designers dilemma in actually

designing a hospital nursing unit, a difficulty which applies equally to other building

types. However, not all requirements are equally important. Besides the problem of establishing priorities, as noted earlier some requirements actually conflict with

others requiring trade-offs. In actual practice, the designer has several means to help him in coping with these numerous requirements. First, there are the building

codes and regulations dealing with those requirements associated with safety.

Second, the designer can rely on books, articles, and other published materials. And

third, the designer can utilize the expert opinion provided by consultants, physicians,

nurses, administrators and others.

The prime purpose of our evaluation methodology was for evaluating schematic

drawings of different nursing unit designs. This purpose, which involved many levels

of comparison, required the development of our own means for handling the numerous performance requirements. We did this by means of a nursing unit schematic drawing

scorecard. The scorecard is shown in Figure 2. Reading down the left hand of this scorecard are the letters A, B, C, and D. These letters designate the different schematic drawings of nursing units to be evaluated. Thus, a total of four different nursing unit designs can be evaluated through

the use of this scorecard.

The column marked "x/o" identifies only those requirements that can be evaluated

from schematic drawings. For each performance requirement that can be evaluated by

using schematics, an "x" is entered into this column. For those that can't be evaluated from schematics, such as our earlier examples of "Provide conditioned air," and

"Provide appropriate levels of temperature and humidity," an "o" is entered into this

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column. However, a schematic drawing is essentially a model of a completed nursing

unit. Like all models, the schematic drawing emphasizes certain features of the

completed nursing unit and ignores others. Because of this lack of comprehensiveness

in schematics, not all performance requirements can be evaluated on the basis of the

schematic drawing. In our evaluation of nursing units based on schematic drawings,

those requirements marked with an "o" are thus ignored and not evaluated. If the

evaluation was based on an existing nursing unit, such as would be the case in feedback studies, those requirements marked ''o" would, of course, be included.

Reading from left to right on the scorecard, the next column is marked "d/e". In "real life," the designer does not have perfect freedom in design but must meet a certain number of legal requirements contained in building codes, regulations and other

documents. The failure to meet these requirements usually would result in disapproval

of his design. Column "d/e" reflects this reality. Each requirement was reviewed to see if it was usually required in building codes, regulations or other documents. If

a requirement was usually legally required or could seriously affect operations, an "e" was entered representing a desirable requirement.

The next column to the right is marked "W", representing weight. Not all requirements, whether considered desirable or essential, are of equal importance. Each

requirement was reviewed by a team of consultants experienced in the planning, design,

and construction of medical facilities. For those requirements judged of extreme

importance, a weight of 9 was entered into column "W"; for those requirements of very

little importance, a weight of 1 was entered into column "W

. " Requirements considered

between these two extremes were appropriately weighted.

This concluded our initial preparation for the evaluation of the nursing units. The

remaining columns shown on the scorecard will be explained in the following description

of our evaluation procedure.

USE OF THE EVALUATION METHODOLOGY

Following the development of the methodology, we evaluated three schematic drawings

of different nursing units. These three drawings were designed to our specifications

by a private hospital consulting firm. Each of the three designed nursing units had

twelve (12) double bedrooms, twelve (12) single bedrooms and similar support spaces

such as nurses station, clean supply, treatment room, etc. The differences between

these three nursing units' drawings was of the arrangement of spaces. Scheme A was arranged into two double loaded corridors, sometimes called the racetrack design. Scheme

B was arranged into one long double loaded corridor. Scheme C was a square radial, that

is, a square nursing unit with the nurses station found in the center with good circulation to all patient bedrooms located along the perimeter of the square. These are illustrated in Figures 3, 4, and 5. Thus, these three specially designed nursing units represented the situation of

alternative designs being developed from the same architectural program, or design

specif i cations

.

After the schematics of Schemes A, B, and C were developed, a physician and an architect from a hospital consulting firm examined these designs against the previously

described scorecard. For each requirement that had been marked "e" for essential, the

three schemes were examined independently by this physician and architect to insure that

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the three designs had some provision for each of these requirements. It was found that

each of the three designs met those requirements marked "essential" to some degree or other. If it had been found otherwise, i.e., that one scheme did not make provision for one or more requirements marked "essential," then that scheme would have been disqualified

from further evaluation. This procedure thus provides a check on design practice. That

is, designs not meeting codes, regulations or other requirements or designs containing

obvious dysfunctions to normal operations, are easily identifiable and can be discarded.

Following the analysis for "essential" requirements, the physician and architect

independently rated each requirement that could be evaluated based on schematic drawings.

This was done by entering a "5" in the column marked on the scorecard for those plans

that met the requirement excellently and by entering a "1" in the same column for those

schemes that only provide for the requirement minimally. Between these two extremes,

ratings were entered based on the judgment of the evaluator. After all the requirements

were rated in the above manner, the rating (column R.|) was multiplied against the weight

(column W) to give the score, then entered into column S-j, the individual scores for

each of the three nursing unit plans.

After this first evaluation, the two evaluators went through the ratings for each

requirement a second time and entered their ratings in column R^. As in the first

evaluation, a score for each requirement was developed by multiplying the second rating

(column R2) times the weight (column W) and entering the result into column S^. Also

like the first evaluation, the scores of the individual requirements were summed to give

a total performance score for each of the three nursing unit schemes.

These two evaluations provided us with a total of four performance scores for each

nursing unit design, two from the physician and two from the architect who had performed

these evaluations. We then averaged these four scores for each nursing unit to provide

an overall average score for each nursing unit. The overall average score for each of

the three schemes is shown below.

Overall Average

Scheme A Two Double Loaded Corridors (Racetrack) 1522

Scheme B One Double Loaded Corridor 1699

Scheme C Radial 1576

What do such overall average scores tell us? First, it can identify for the

designer the areas that can be improved in his designs. Using the scorecards, the

designer can develop a list, through low performance scores by going through the

scorecards and extracting all requirements that did not receive a perfect score.

He can then arrange these in a priority-rated list with the first requirement being

that one which had the greatest difference between its actual score and its perfect

score. Through this method the designer can then achieve positive feedback on his

designs prior to construction. Through the use of this positive feedback, the designer

can improve his designs for the nursing units.

A second advantage is that these overall scores can aid us in making a decision

on what schematic plan should be used in the new hospital under consideration. To make such a choice however, we can not consider the overall average scores alone.

Rather, we must add the cost factor. To provide such a cost measure, we made the

simplifying assumption that construction costs are a function of floor area. That

is, we can calculate the construction cost for each of the three plans by multiplying

73
the gross square feet in each plan by a dollar per square foot factor. This method

of cost estimation is commonly used during planning of new hospitals. Of course it

does not provide the accuracy of a cost estimate based on a quantity take-off. The

factor we used to do this was $45 per square foot ($484.4 per square meter). Our

estimated construction costs for each of the three schemes was as follows:

Construction Costs

Scheme A Two Double Loaded Corridors [Racetrack) $558,000

Scheme B One Double Loaded Corridor $522,000

Scheme C Radial $603,000

So we now have an estimated construction cost for each of the three schemes and

an overall average score of performance for each of the three schemes. Borrowing from

the methodology of benefit-cost analysis, we can now compare these three schemes on a diagram as shown in Figure 6. In this diagram the axis is the overall average score

of performance or predicted performance since our evaluation was based on appraising

and comparing schematic drawings. The y_ axis is the costs. The line of maximum,

performance is the total possible score that can be achieved. The boundary shown at the right side of the diagram is a theoretical line that represents the concept that

the more money spent the closer you will come to maximum performance. On this diagram

are plotted our three nursing schemes A, B and C. On this diagram, the most desirable

solutions are those that fall to the bottom right of the diagram. That is, those

solutions in the bottom right provide the least cost and the most performance. In our evaluation there was only one such scheme to fall in this area. Scheme B. From this

diagram, it can be seen that Scheme B offers the advantages of the least cost and the most performance and therefore is superior to Schemes A and C.

In our particular evaluation, as stated, it so happened that only one scheme fell

in the lower right hand region. Probably this would be unusual in most evaluations of

this type. Rather than a single point in this area, probably the more usual occurrence

would be two choices--one scheme having lower performance but costing less and the

other offering higher performance but costing more. In this case the decision maker is faced with no easy decision but one of value; i.e., is it worth it to pay more money

for more performance? Although there is no easy resolution to this question, the above

described evaluation methodology can provide information on what areas of improved

performance will be bought for the additional cash outlays required.

The development of our evaluation methodology for nursing units, how it works and

how it can be used have been discussed. However, it is also necessary to discuss the

future enhancements of this methodology that we intend to address.

FUTURE ENHANCEMENTS OF THE METHODOLOGY

First, requirements should be generated using more people than the few employed

in the initial investigation. This procedure would be valuable because this initial

"pool" of performance requirements can probably be enhanced through the use of many

more experts in this field. A Delphi technique might be used to accomplish this result.

In addition, the initial development of the performance requirements relied heavily on expert opinion. Ideally we would like to generate such requirements through architectural psychology studies of nursing units, studies that are now very few in number.

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Second, rating system and weightings were likewise based on the results of few

subjects. Like the generation of requirements, this data base can be improved by

increasing the number of individuals involved, through techniques such as Delphi. In our study this was not attempted due to time and budgetary limitations. Beyond expert

opinion, improvements may also be possible by utilizing psychological ranking systems

such as Abraham Maslow's "Hierarchy of Needs" to develop an objective system, a study

we would like to undertake.

Third, only the qualitative portion, the requirement, was used in the evaluation

methodology described. It would be much more desirable to include the quantitative

portion, the criterion, in this methodology to enable evaluators to have an objective

basis for ratings. The development of criterion associated with the performance

requirements would also allow the development of performance specifications, to be

used in the planning, design and construction of new medical facilities.

Fourth, our method of calculating costs, i.e., by cost per square foot times gross

square feet, represents a simplifying assumption. Actually, initial construction costs

are a function of many variables such as the area of the perimeter wall, length of runs

of utilities, etc. The use of such techniques as regression analysis could provide an improved method of estimating initial construction costs. However, detailed and accurate cost data upon which to base techniques such as regression analysis are generally

lacking. Hopefully, this situation will improve in the future.

Fifth, and finally, we used initial construction costs in our evaluation methodology. It would represent great improvement in this methodology if we were able to use expected life cycle costs rather than initial construction costs. However, even to a greater degree that initial construction costs, data on life cycle costs are almost

entirely lacking. This is a problem that many building research organizations are addressing. As data on life cycle costs are collected, analyzed and disseminated in the future; we will be able to incorporate expected life cycle costs in this evaluation

methodology.

SUMMARY

As mentioned, we are presently faced with a trend toward greater costs in our

new medical facilities at the same time that more Americans are seeking a greater access

to our health care delivery systems. The burden of these twin trends fall most heavily

on the hospital planners and designers. Because of these trends, these planners and

designers must become increasingly aware of the multitude of requirements and their

associated trade-offs, must be satisfied. The evaluation methodology that has been

discussed today is one method of enhancing this awareness and of aiding these planners

and designers to produce more effective and efficient hospitals.

We have only discussed this methodology in the context of the evaluation of schematic drawings of different nursing units. However, this same methodology can also be

used to aid medical facility planners, to aid in the generation of facility requirements,

to use in checking design drawings prior to advertising and for other uses in the

pi anning--design--construction process. This is possible because the evaluation methodology described can ultimately provide a complete and comprehensive framework for our work in medical facilities.

76
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1. PUBLICATION OR REPORT NO. NBS-BSS-54

2. Gov't Accession

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TITLE AND SUBTITLE

Proceedings of the First Federal Agency Workshop on

Health and Medical Facilities Design

5. Publication Date July 1974

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VUTHOR(S)

Robert J. Kapsch, Editor

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SUPPLEMENTARY NOTES

Library of Congress Catalog Card Number: 74-105 61

ABSTRACT (A 200-word or less factual summary of most significant information. If document includes a significant

bibliography or literature survey, mention it here.)

The Federal Agencies have a large involvement in this area of

Medical Facility Design; both in directly operated Federal facilities

and indirectly through grant, loan and funding programs. Because

of the impact of technology and because of the very large cost for new

medical facilities; in the last few years there has been the rise of a

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presented at a National Bureau of Standards' Federal Agency Workshop,

describe the latest medical facility research efforts by the Federal Agencies

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Welfare, the Veterans' Administration and the National Bureau of Standards.

KEY WORDS (six to twelve entries; alphabetical order; capitalize only the first letter of the first key word unless a proper name; separated by semicolons ) .t • j- i Architecture; design; hospital design; medical facilities; medical

facility research.

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