Faster and More Efficient: How the Pandemic Has Sparked Project Delivery Innovation

December 1, 2021

Principal, NBBJ

Editor’s Note: We believe that strong project management drives great design. In this four-part series, we will explore four different and important aspects of project management. The first post in the series—which was originally published by Project Management Institute—focuses on accelerated and innovative delivery methods.  

This post was co-authored by Sarah Markovitz and Kwang Lee.

One of the challenges facing hospitals across the country has been the urgent need for space due to the COVID-19 pandemic and increased emergency psychiatric visits. In this context, it is especially important to deliver projects as quickly as possible, all while maintaining social distancing measures during design and construction. According to a Health Facilities Management survey, almost a third of recent hospital projects have been fast tracked. This critical need for faster delivery has spurred new virtual and logistical approaches to project management, including our work with Massachusetts General Hospital on its 7,050 square foot Acute Psychiatry Service project.

The project team, led by NBBJ (design) and Walsh Brothers (general contractor), worked with a compressed schedule which enabled Mass General to finish the project more than 30% faster than initially planned, while accommodating changes requested by the hospital during construction. From this experience we have distilled three key strategies, described below, that can deliver projects faster and more efficiently—streamlining the request for information and user engagement process, developing Building Information Models (BIM) in collaboration with engineers and consultants early in the design process, and using platforms like Open Space to rapidly track on-site progress virtually.

Streamline the Request for Information (RFI) and User Engagement Process
Needing to quickly create new psychiatric space to shift psychiatric patients out of a cramped emergency department, Mass General developed a compressed project timeline. Accommodating this schedule required NBBJ to develop a new process for responding to construction related questions and reviewing submittals. Typically this takes one to two weeks and involves several engineers sending documents back and forth to identify and work out design and technical issues.

To keep to the compressed schedule, NBBJ committed to a one day RFI response time and introduced group Zoom calls with the relevant project team members—from engineers and equipment suppliers to security contractors and door consultants—to quickly coordinate live comments.

A similar Zoom-based approach was used to streamline the user engagement process. The Mass General Emergency Department staff wanted to participate in the construction meetings to check the construction process and to relay last minute design change requests. This virtual meeting enabled the project team and client to communicate quickly while maintaining social distancing measures and also allowed a range of stakeholders to participate even at the peak of the pandemic period.

Develop Collaborative BIM Models Early On
With a compressed schedule, it was important to ensure early coordination between the design and construction team. Recognizing the need for more accurate bids to save time and money, the team invested in earlier, more complete BIM development, coordinating with engineers in the BIM model before they would typically be engaged in the design process. As a result of this approach, the project received far more accurate bids and minimized the amount of changes needed during construction, enabling a faster timeline.

Early BIM development was particularly important as a portion of the project is located in a building built in the early 1800s, with a very low ceiling. NBBJ collaborated closely with a mechanical engineer as well as the construction team to find the right routing for a new mechanical system in the tightly packed ceiling space.

In the same spirit of collaboration, the design team worked more flexibly with the general contractor on construction material selections, recognizing the need for substitutions on certain items due to their impact on the schedule. With widespread material shortages, especially for items with microchips or items coming from overseas, it was critical to both order materials early and be flexible with substitutions in order to maintain the project’s tight schedule.

Use Virtual Platforms to Track On-Site Progress
Given the pace of the project schedule, it was critically important to maintain a high level of coordination among all team members to identify clashes and track on-site progress. The team used Navisworks, a design collaboration tool, to coordinate with engineers and mechanical subconsultants to identify any conflict between existing and new mechanical systems weeks before they would typically be discovered. The team also held weekly meetings to review clashes and find alternate solutions.

This process was greatly enhanced through the use of virtual platforms like Open Space, which maps live jobsite photography to plans. Using Open Space, construction team members were able to to walk through the construction site with a camera that takes pictures at regular intervals, creating a point-to-point virtual 3D model of the project. This enabled the team to quickly identify, collaborate and resolve issues, and create a visual reference model that was readily accessible online. It also reduced on-site visits, which saved time and reduced infection risk.

Open Space was particularly useful for this project as the team had to work in a highly coordinated fashion to adhere to the project timeline. On a typical construction project, the trades would work sequentially, moving from work like MEP ductwork and electrical to finishes and flooring. But to maintain Mass General’s schedule, the trades worked more concurrently—adapting measures like installing and protecting flooring so that other trades could continue work. This required the design team to push forward on submittals and order materials early. Using Open Space reduced the number of people working on and visiting the site and enabled faster coordination.

While these project management strategies may not be applicable to every project, they can help to streamline the design and construction process—particularly when the schedule is an overriding concern. Given the ongoing restrictions to in-person collaboration and collocation due to the pandemic, and the critical need for more clinical space, the adaption of virtual tools and strategies like these will likely gain traction as clients look to complete projects quickly, safely and more efficiently.

 

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Going Up: Why Vertical Hospitals Might Be the Next Frontier in Healthcare Design

November 1, 2021

Partner, NBBJ

As cities densify, land values increase and the need for outpatient care services rise, hospitals are increasingly challenged to find space to expand. While true in many regions, this is especially so in cities like New York and Singapore, where vertical hospitals are a viable, and in some cases the only, option for significant hospital expansion.

At NBBJ, we practice primarily in urban centers and specialize in healthcare design. So, when faced with this challenge for a project in London, we designed a vertical “healthcare village” concept that focuses on greater efficiency and experience. In this article, we’ll explore the opportunities and challenges of high-rise hospital design, as well as the main ideas and themes we considered when designing the new medical facility for the heart of London.

Opportunities and Challenges
The concept of healthcare villages—multi-use environments that integrate healthcare with commercial, residential and other services—has evolved for over a decade. The first healthcare village in the United States, the Metro Health Village in Michigan, opened in 2007, and Guys and St. Thomas’ NHS Foundation Trust in the UK refers to various spaces within the hospital’s Cancer Centre using this terminology. But the concept of vertical hospital design and vertical villages has only recently gained popularity.

Part of the need for a high-rise hospital village concept is the increasing co-location of clinical and research functions. This trend creates more travel between buildings and campuses, which then leads to an inconvenient and unproductive experience for staff. Tall hospitals can contribute to a better experience by minimizing the movement of patients throughout the building, locating key equipment and services closer to patients and bringing more services to a diverse population. And, because they are often located in urban environments, vertical hospitals can tap ancillary revenue streams like leasing out ground floor retail or building in conference or meeting space to bring retail and other services to neighborhoods.

Compared to the Low-Rise layout shown above, a High-Rise hospital layout simplifies wayfinding, creates efficient travel distances and provides greater access to daylight and views.

 

However, high rise structures are complex and designing for healthcare brings additional challenges. Airflow, MEP equipment and structural engineering must all be considered. Healthcare environments are also likely to experience future expansion and adaptation, so considerations like building load capacity in columns and floors, fire proofing and utilizing a modular grid must be addressed to ensure that the building is flexible. And, without the benefit of separate buildings for separate practices, creative wayfinding, connection and patient and caregiver flow solutions are important in the design of vertical healthcare environments.

A Series of Vertical Villages
When tasked with designing a vertical hospital village in London, we applied our expertise in designing both healthcare environments and high-rises to redefine what a city center hospital can be. Different villages or hubs for education, private and inpatient care, maternity, critical care, pediatrics and imaging are located on separate levels and defined by greenery, winter gardens and landscaped terraces and walking paths throughout. Technical considerations such as efficient vertical transportation and core size, as well as employing off-site and modular construction for select elements, are key to maximizing the available footprint. Three main design aspects guided our vision and successful implementation of the vertical healthcare village:

Form and Function
In our concept, the villages are given different identities but possess the same ingredients in terms of access to the outdoors, greening, and collaborative and family spaces. This differentiation also helps to break up the overall mass and provide visual interest, and simplifies wayfinding, creating a sense of place for staff, patients and visitors. Individual elements of the facade vary according to orientation and use within but share an inherent verticality collectively benefitting the proportions. Finally, all heavy equipment is housed in the lower levels, with the less technical floors situated above. This contributes to a stronger structure to counteract vibration and offers flexibility within both the structural environment and technical spaces.

Staff and Patient Experience
Diverse environments within the space support normalcy for patient families, emphatically integrating caregivers and families into the care process. Amenities like yoga and dining, and places for respite with access to nature and views nurture staff’s well-being as well as that of the patients and their families. And, short vertical distances are prioritized over long horizontal distances, which means more efficient travel for both patients and staff.

A Healing Environment
The internal experience for staff, patients and families explores the relationship between health and physical space to streamline operations, enrich the staff and patient experiences, and improve outcomes in healthcare delivery. Considerations such as enhanced access to daylight and views to most of the floorplate, as well as improved air quality and reduced noise benefit the healing process.

The tower’s stacked volumes are separated and articulated by vertical and horizontal greening, with atriums that create respite hubs every two to three patient floors.

 

With gains to be made in staff and patient experience, excellence in clinical delivery and build efficiency from modular construction of towers — especially in tight urban environments with limited space for construction—going up may be the way forward for healthcare provision in urban environments.

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Balancing Beauty, Dignity and Safety

Furniture and Finishing Strategies for Behavioral Health Facilities

October 21, 2021

Principal

A critical challenge in behavioral health design is the need to balance aesthetics, dignity and comfort with safety. This is especially true when it comes to the interior. Furniture and fixtures designed for these environments have historically exuded an institutional feel which undermines the familiar, calm, healing environment that research suggests is required to promote good outcomes. This challenge is particularly acute on projects which serve diverse patient populations with a range of needs—such as the Big Lots Behavioral Health Pavilion at Nationwide Children’s Hospital, the largest pediatric behavioral center in the nation. However, by building on evidence-based research and design R&D, and considering not just how furniture looks and functions but how it can be adapted and maintained over time, behavioral health facilities can reinforce both dignity and healing. Below are four key elements to consider when devising a furniture strategy for behavioral healthcare facilities, drawn from our research and experience designing the Behavioral Health Pavilion in collaboration with architecture+.

If It Doesn’t Exist, Design It
In researching furniture options, the Behavioral Health Pavilion team found that existing products tended to emphasize durability at the expense of comfort. To address the specific needs of a patient population which included both teenagers and younger children, more reassuring, comfortable furniture was needed, which at times required a custom-built solution. For example, the patient rooms, which are designed to feel more like dorms or living rooms, required a sleeping and seating platform which provided space for family and was made of natural, durable, economical materials.

Unable to find a commercially available product which met these requirements, the team created a L-shaped built-in bed with space for storage and for parents to sit, lie down and spend time with patients during their recovery process. Built by local millworkers, the custom element uses stacked plywood as a more economical wood option, which maintains a durable yet natural feel that takes on an appealing patina as wear and tear accumulates. Mockups—which served as a real-world example of the building’s aspirations for a more comfortable, familiar type of care environment—were used extensively to work out the design details, and as a tool to help raise mental health awareness and secure sponsorship through touring state legislators, community leaders and donors.

Ensure Adaptability
While furniture in behavioral health settings must be safe, durable and attractive, it should also adapt to different functional needs so that a seamless design aesthetic can be maintained across program areas and over time. Furniture selection for the Behavioral Health Pavilion was driven by this central premise. For example, all specified furniture adhered to a few pre-established contrasting options (soft vs. hard, light vs. heavy, assembled vs. molded) to ensure safety requirements were met and that all the pieces worked together harmoniously as a carefully curated yet highly flexible collective.

For example, chairs used in common areas can be filled with sand, making them heavier and less movable for spaces where safety protocols require it. The team also worked with the manufacturer to develop a durable tablet arm for the chair used in patient rooms, so that it could also be used in exam and consulting rooms. This strategy enabled the design team to use similar furniture in public, staff and patient areas, helping to normalize and destigmatize the patient experience. The approach was guided by evidence-based research suggesting that the design of an environment can help reduce stress and improve outcomes, especially if it promotes a normal, familiar atmosphere.

Use Modular Approaches
Because of concerns about safety and damage, durability is a critical consideration in furniture designed for behavioral health facilities. At the Nationwide project, furniture and fixtures were selected and designed to be modular wherever possible, so that damaged elements can be easily replaced. The bed and seating units in patient rooms and curvilinear seating benches in common areas, for instance, are modular and consist of removable segments to facilitate repair and maintenance. This approach also extends to the flooring, which is seamed in such a way that any single floor piece can be removed and replaced quickly while patients are elsewhere in the building, minimizing disruption.

Conceal Safety Features
Maintaining an uplifting and supportive atmosphere requires close attention to detail, including the concealment of institutional-feeling safety features. The informal motto “always present, never seen” serves as a frame of reference for the design, where safety infrastructure is embedded in the environment in subtle ways. Safety and prevention of self-harm are carefully considered in how materials are installed, joined and assembled—including understated, stylish tamper-proof lighting systems, and double action door hinges which are barely noticeable and ensure rooms are barricade proof. When available options felt too institutional, the team collaborated with manufacturers of bathroom fittings—including lighting, mirrors and soap dispensers—to use more understated products not yet on the market in exchange for feedback on their designs.

As behavioral health facilities evolve, there will be increasing opportunities to use furniture and fixtures to enable safer facilities that more closely resemble homes, schools and other familiar settings. This will require a considered approach that builds on research and strategies such as those discussed here to create more empathic environments that destigmatize behavioral healthcare and truly encourage healing.

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