Multiple benefits of a standardised approach

Building new hospitals is complex, and schemes are often over budget, delayed, or beset with unforeseen complications during the construction phase. Fewer and fewer contractors want to take on hospital projects as a result of the risk, placing the ability to deliver new healthcare facilities at the scale and pace needed under threat. Can that risk around these projects however be reduced by standardising the design to remove the variability and give cost and programme certainty? Mott MacDonald Technical director for Healthcare, Andrew Parks, and Global lead for Industrialised Design and Construction, Ben Carlisle, both believe that taking an industrialised construction approach could do this, and more. However, taking this methodology calls for change across the healthcare sector.

To demonstrate the need to find an alternative approach, Ben Carlisle says that it is currently likely to be more profitable for construction firms to build offshore wind farms in the North Sea than it is to deliver a hospital project in a city centre.

He says: “That doesn’t feel logical, but the offshore wind sector is highly modular and standardised, and, despite the offshore location, that reduces the risk. It is clear that we cannot keep using the same approach to building hospitals and expect it to deliver a dramatically different outcome. If we truly want an alternative result, then we must seek out new methods and delivery models in healthcare.”

Three key benefits

Andrew Parks agrees, and says that there are three key benefits to standardising healthcare facility construction: improved decision making, better management of complexity, and reducing the risk profile of projects. He says: “Decision making in healthcare focuses on getting a hospital built quickly, leading to rushed, premature decisions, such as building a hospital without properly understanding what the need is, and jumping into designing a new hospital too quickly. Standardisation helps in understanding problems objectively, and making better decisions earlier in the process.”

According to Andrew Parks, the complex nature of developing a new hospital, and the number of stakeholders involved, means that changes on part of 
the scheme can have unforeseen negative impacts on others. “Standardisation helps manage this complexity 
by providing an integrated, structured approach to design,” he adds. When applied to a programme of schemes, standardisation also reduces variability, and addresses the risk profile on each project, leading to continuous improvement and learning. This is a move away from each project tackling the same problems over and over again, and potentially making the same mistakes.”

Reducing the capital costs of construction

As well as improving outcomes for staff and patients, standardisation can reduce the capital cost of construction, while also having a beneficial effect on operational costs. “Through standardising you are simultaneously designing and integrating operational solutions,” Andrew Parks explains. “So, you’re not creating a building with a separate digital plan and a separate workforce plan, but rather designing everything to work together, so operationally they perform and function better. This integrated approach improves certainty that the outcomes delivered by the work will be realised at every lifecycle of the new healthcare facility.”

While many countries have yet to adopt a standardised approach to healthcare facility design and delivery, there are examples around the world that can be looked at to draw lessons from.

“Australia is a good case study for this,” says Andrew Parks. “There they spent a lot of time thinking about how you standardise the requirements of the hospital. It has improved the delivery of the construction, and had a significant impact as a result.”

Ben Carlisle adds: “The Australians are taking a very digital approach, and have really focused on standards — standard rooms, standard equipment, and standard data sheets — and have mechanisms in place to publish and update them. This allows documents to be submitted electronically, with the design automatically checked against standards for compliance.”

Andrew Parks says: “A similar approach to standardised design has also been taken in Denmark, and while that has had mixed results, with certain elements being better than others, there is a lot we can learn from that work too.”

Standardisation’s use in other sectors

The use of standardisation by other sectors also 
creates a knowledge base for healthcare. Andrew Parks points to the use of the product platform approach (see box) to standardisation being used in the UK by the Department for Education on schools, and the Ministry of Justice for new prisons. “The experience from using product platforms for prisons and schools projects tells us that early contractor involvement in the design is critical,” he explains. “The use of the concept in schools also provided the understanding that you can’t design an entire new system in one go; it needs to be done in stages.”

Ben Carlisle adds: “The Department for Education 
also sought to take the market with it, and developed 
an iterative, open, and collaborative approach. It took 
the business model forward in steps that capabilities 
and training in the market could cope with. This was all built on a solid foundation of what actually needs to be 
in a school, and only evolving those definitions very slowly.

“The Ministry of Justice took a slightly different route because it cares about different things — principally security and welfare — so has focused on certain aspects, such as windows, and left other elements to the market to determine.”

Analysis undertaken by Mott MacDonald for the Construction Innovation Hub’s The Value of Platforms in Construction report1 showed that use of product platforms could translate to a potential saving to government of
£1.8 bn a year across social infrastructure. At a project level, that could reduce the cost of a hospital by £147 m.

Delivering a step change

Understanding the issues that result in hospital projects being late and over budget helps to underline the benefits that standardisation could bring to such projects. One of the key problems is that each build is treated as a brand new, individual project, and the supply chain has to mobilise each time. With a standardised approach, the supply chain already knows what is wanted, and can build a business around that.

“With a platform approach, the trades can do what they are good at doing, and what changes is the way they go together,” explains Ben Carlisle. “The uncertainty, the risk, and the waste arise because although we know we’re going to have a floor, windows, doors, ventilation, lights, nurse call systems, and gas supplies as the basics, they all get arranged and integrated in a different way each time. While the component parts are pretty similar, because of the design development process, and the influence afforded to a broad range of stakeholders in that process, we end up having to develop solutions differently each time. This makes it hard for the market to learn, invest, and improve.

“Standardisation therefore needs to recognise the necessity for as much commonality as possible, but as much variability as required too. This changes the way that design is done to make it more ‘modular’, so that stakeholder choice and localisation can be accommodated without changing everything. So, it confines choice to where it is valuable, and minimises change caused by choice. Conversations that are normally repeated on every hospital project are had once, but where localisation is needed, the implications are already understood.”

The operational model

However, standardisation extends beyond the build phase, and is about the operational model of the facility too. Andrew Parks says: “Standardisation must also consider the interfaces between clinical, workforce, and the patient, to ensure that best practice is considered, and the scenario tested upfront once, learned from, and tested again, before being validated, so that it can be repeated.”

As a result, not only could standardisation reduce initial cost and the operational costs of the healthcare building itself, but it could also improve patient care and outcomes. By starting with a standard design to hospital spaces, combined with an integrated digital system, as well as integrated services in those spaces, staff and patients can transition easily from one part of the hospital or system to another. Andrew Parks adds: “Without the consistency that standardisation brings, this type of transformational change is not possible. Through standardisation, we move towards a system of healthcare facilities where patients and staff can easily move between them, as opposed to individual hospitals.”

Culture change

One of the major barriers to standardisation is the different way that each hospital functions. Operating models and models of care within the hospitals need to integrate into the system so that they don’t operate as individual entities but as part of the system. However, this requires a substantial cultural change.

Ben Carlisle added that taking a more standardised approach will call for change in the construction industry too. The sector is currently highly fragmented, and while school and prison projects are starting to shape the sector for standardisation, the supply chain is not yet fully ready. He believes that the construction industry needs a long-term, stable, and visible pipeline of suitable projects across the social infrastructure sector in order to adapt and change.

He adds: “Having an order book of work in this way creates the opportunity for a pipeline of component parts which is enabled through standardisation and the use of rules. For example, if we have standard rooms with standard equipment, we can make pretty accurate estimates of quantities of, for example, medical gas outlets, doors, and bathrooms etc. very early in the design process. This helps with market visibility and engagement, as well as improving decision making.”

What is clear is that for healthcare facilities to reap 
the benefits of standardisation in the long term, all 
parts of the supply chain and those working in 
healthcare will need to accept change and the iterative process that is necessary to deliver that. The change 
must also extend to how new healthcare facilities are funded. Ben Carlisle adds: “It is well proven in the nuclear sector that a first of a kind design is improved with each further iteration. The first of a kind is always more expensive than the second, but we typically see a 20% improvement from the first, to the second, to the fourth, to the eighth, to the sixteenth. We glimpse these learning effects at a project level too — with improvements made floor-by-floor in building construction — but variability makes it hard to scale.

“The way hospital projects are conventionally planned and funded as ‘one offs’ makes it very difficult to make trade-offs across different schemes and harness the learning effects. We need to be able to say we are going to invest in one hospital as a pathfinder, with the knowledge that the first one is going to cost 10 to 20% more than the second one.

“The way that we approach it in construction is we measure, and we lock everything in a project that has its budget, targets, teams, and incentives. The next one will have slightly different teams, slightly different incentives, and slightly different targets. For standardisation to be successful, we need to break that kind of delivery model, and find ways to encourage repetition and learning.”

Future vision

Looking ahead 20 years to 2045, healthcare facilities could look and feel quite different from today if standardisation is achieved, according to both Ben Carlisle and Andrew Parks. They envision a healthcare system that continuously learns and improves, with better integration of digital systems, more efficient processes, and improved patient outcomes.

“How you conceive and plan a hospital and engage stakeholders and communities should feel totally different by then too,” says Ben Carlisle. “It takes four to six years now, but it should only take a year in the future if we are successful in adopting standardisation.”

He also believes there will be improvements in the way facilities are operated and managed, with standardisation creating the opportunity for digital twins and common data formats across the common designs. “With this information,” he says, “you can start spotting patterns across multiple hospitals, rather than just one, so you know if something is out of the ordinary, or more systemic, and deal with it accordingly.”

It is clear that the tools exist to make hospital projects less risky to build than offshore wind schemes, but the big question is whether all parts of the sector can work together to get there.

Reference

1 The Value of Platforms in Construction report. Construction Innovation Hub. April 2023. https://tinyurl.com/bdfyu9vw