The Science of Low-Cost Healthcare Design
By Ar. Nandini Bazaz
Drawing on over more than 20 years of experience designing hospitals in India and abroad, Nandini Bazaz, Director, Architectural Services of HOSMAC provides a cost management toolkit of key ideas and cost management strategies at how the leadership team need to look at the design of the hospital.
Cost-cutting is usually an unglamorous subject for a healthcare executive. However, it is a timely issue. Here are some ideas, tips and tricks, the sneaky-ways cost can be created, and some smart ways to cut the cost.
1. Where can you cut costs?
Area per bed is a ball-park ratio which is derived from a space program. This number must be followed as hospital planning progresses since this is directly related (proportional) to the number of beds in the hospital. In villages and small towns in India, 650 square feet per bed allotment to hospitals is acceptable as accommodations are inwards; where-as in metropolitans 1000-1200 square feet per bed is the allocation as per standards that may apply in the respective geographical region. The above and more savings can be achieved through calculations of areas by experienced teams of professionals, architects/engineers/healthcare planners who can plan hospitals in shorter time and resources.
Another valuable time saving and useful cost-cutting idea is to plan the hospital's structural grid in less or optimum span required for inpatient rooms and operation theatre arrangements, keeping in mind trends for parking cars which need to fit well in this grid. Wider grids tend to increase the cost slightly so one should make a judicious tradeoff.
For example, teaching hospitals will be planned as per ward layouts, lesser widths in column to column grid. In contrast, the grid of multispecialty hospitals will have larger spans as they are planned for standardized inpatient rooms plus car parking bay sizes have to be met with too. These are quite different structural grid typologies, and if done right the first time, enables a reduction in the cost of construction of the building. Shorter spans allow lesser beam depths which means less steel and concrete utilization.
Mechanical, Electrical, Plumbing and Fire-Fighting planning constitutes a high cost to a hospital at around Rs 1300-1500 per square foot. This being one of the more significant infusions in terms of expense for air-conditioning, electrical and plumbing services, plus fire-fighting systems naturally ask for careful planning of equipment installations to then cut on the CAPEX as well as OPEX.
Here are some examples to enable energy conservation:
LEDs and compact fluorescents (CFL) can provide three-year paybacks.
Selecting an energy-efficient HVAC system as it impacts both CAPEX and OPEX. Life cycle costing is the best way to choose optimal technology.
Daylight sensors can decrease lighting loads during the day when natural light is available.
In the area of interior design, it is a prudent exercise to source raw materials from the same area, in context to where the hospital is being built. This is how vernacular architecture can be best made to work in as climatic, geographical as well as the responsiveness of the natives is best applicable.
It is advisable to cut on the frills of interior design and looks by importing materials as well as labour to build the hospital from far off places, especially foreign lands. Hence, if one can use the skills of local artisans for construction, then inevitably it enables good CAPEX. For example, terrazzo is the age-old way of constructing floors which are durable in the long run. Locally available stone can be made use of to build decks as well as coping material and in landscaping too. Hence, locally available materials of construction are a definite plus for CAPEX, as transportation cost is reduced and maintenance after years of use is expertly handled.
2. What is the recovery period?
Break-even period will be after the facility has run for say 3-4 years when the operational income crosses the expense. The recovery of CAPEX invested is generally after 10-12 years.
For this, the above strategies of energy conservation, use of locally available materials, improved (optimum) indoor air quality maintenance and more, need to be carefully, distinctly planned within the contextual setting of the building.
3. How much can you reduce?
The average reduction can be between 15-20% of CAPEX if the mentioned approaches in Architectural, Structural, Mechanical, Electrical, Plumbing, Firefighting and Interior Design can be effectively implemented.
4. What to cut/What not to?
As Building orientation is the priority, climatic effects must be studied at the beginning of conceptualizing the hospital building on its site to manage the CAPEX. Aiming to harness natural ventilation for 65-70 per cent through building's surface area can be achieved by taking advantage of unique prevailing breezes of the land through seasonal studies. If building's longer side is oriented towards North in India, it enables reduction in air-conditioning of indoor air as solar heat gain on the surface is minimal, thus reducing the OPEX for HVAC systems.
In case the western to the eastern side is exposed to sun, then a double wall system or insulation in the external walling system may be required to keep the inside of the building cool. Hence site studies are essential, and therefore ought to be prioritized at the conceptual stage of the project. The architecture of the hills is different from the constructions methodologies of the plains or even the desert.
The clinical areas can be passively cooled and naturally ventilated, with a small percentage of mechanical fan-assisted ventilation installed at ceilings and exhaust fans. Building orientation is an essential factor which enables passive cooling.
Solar panels, thermal mass building construction; green materials including wood, stone, or earth geothermal heating and cooling techniques can be adopted for the reduction in OPEX. The use of low-flow fixtures, rainwater harvesting, and recycled water for various applications like landscape irrigation goes a long way in sustaining the applications.
5. Common mistakes
Some of the most common mistakes are project time overruns. Once a timeline is fixed to enable construction to start and finish at a specific time, one should maintain so, or else both time and finances, flow uncontrollably.
At other times, expensive equipment is ordered well in advance, like HVAC chiller or even medical equipment like MRI machine which is left unattended for months and years till the facility is ready to use.
Load on CAPEX: Execution of MEPF systems without detailed calculations by healthcare planning engineers, and other technical consultants is another slip. This can mean an orchestra unable to play in sync; where the notes go off unknowingly, which can be a severe loss of CAPEX — in short, not hiring experienced teams of architects, engineers, consultants and enablers.
Certifications must be renewed as else are meaningless, and ought to be taken as mistakes in the effective saving of costs of the hospital building. Such systems can turn out to be costly to the stakeholders. Expensive to build and run.
An efficient Building Management System (BMS) is to be run with regular monitoring, checks in occupancy levels, and regulating sleep modes for energy conservation. If this is not in place, again, the direct influence can be on CAPEX plus OPEX as maintenance dips.
6. What are the significant features of a low frill design?
Money can be usually saved in façade, flooring, false ceiling, excessive woodwork, toilets. A low frill design primarily should be able to save energy and mitigate environmental problems; as it is obligatory to be inclusive by design to the users. CAPEX is tenable if these buildings are designed inside out as much as outward-in. So, to say that not only does the health of building's occupant takes precedence but by reducing the pollution from the building to the outside, enables the hospital to contribute towards improving environmental conditions of people in its vicinity, be it the city or a town/village.
Luxurious interiors can be replaced by applying local conservative strategies which are relevant and useful to the public who inhabit these hospitals. Out of vital, essential and desirable, the non-essential features are made use of to allow users to pay lesser charges for clinical services they get. This system thus can become a win-win for both the patient as well as the stakeholders.
Author
Ar. Nandini Bazaz,
Director, Architectural Services
Hosmac India Pvt. Ltd.