Publications IPH Magazine Revista IPH Nº18 RECOMMENDATIONS FOR PLANNING AND CARRYING OUT RENOVATION WORKS IN FUNCTIONAL HOSPITALS

Planning renovation works in operational hospital environments is a complex activity, which requires careful and a multiprofessional knowledge that goes beyond engineering, entering the spheres  of  nursing  and  medicine. With this article,  we try  to contribute to the dissemination of good  practices in this field,  through a methodology aimed at generating  planning  recommendations. During the investigation of the minimum care necessary for the planning and execution of renovation works and expansions of hospitals in operation, a checklist of points of attention and risk matrix was elaborated, demonstrating some actions that can be taken to mitigate critical points and guide construction staff with little experience in works within healthcare facilities. The study was based on a bibliographic survey and on an analysis of relevant standards and legislation. At the end, a number of actions are recommended for the various professionals involved  in the planning  and execution of works in hospitals,  including the Hospital Infection Control Commission, patient-safety teams, suppliers  and other workers of healthcare facilities, in order to avoid harm to patients and health organization as  a  whole.

Keywords: hospital planning, renovation works, risk matrix.

According to Mattos (2019, p.19), the construction industry has been one of the productive branches that have presented the most significant changes in recent years. The  intense competitiveness and globalization of markets, the demand   for more modern goods, the increase in the emergence of new technologies, the change in the  degree of demand of customers and the reduced availability of financial resources for the realization of enterprises have made business organizations realize that investing in process management and control is  indispensable,  because without this mechanism  the  enterprises lose sight of their main indicators: time, cost, profit, return on investment and cash flow.

In the case of investments in Health Care Facilities (EAS), mainly in renovations and expansions of hospitals that are in operation and cannot stop their operations, it is necessary to apply planning tools that  help reduce  their  impacts, which can range from safety of patients, decrease in hospital unit revenue, dissatisfaction of building users,  poor application of investments, among other risks inherent to the  absence of a correct and continued planning.

This research aims to contribute to the dissemination of good practices, guidelines and minimum care that are necessary for the planning and execution of renovation works and expansions of hospitals in operation, through the preparation of a checklist of points of attention and a matrix of risks, demonstrating some actions that can be adopted to mitigate critical points and guide the teams of professionals working withing healthcare facilities.

An engineering enterprise must be developed following a logical sequence of development of the final product, carrying out its phases in feasible time to achieve the objectives outlined for each phase, generating products that will lead to the further sequential phases  (MATTOS A. D., 2019, p. 27). 

The different phases of an enterprise, from its conception to execution are presented in the image  below, in which are indicated the milestones that professionals in the sector use to  measure the  evolution of the project and construction. For example: preliminary design, basic design and detailed design (SBCC: Working Group GT 4, 2012, p. 17). 

The intervention stages include: elaboration of the Strategic Masterplan, the Hospital Physical Masterplan, Management of the Building Documentation, and the Planning and Elaboration of Projects, reaching the Contingency Plan and the Execution of the work itself, from which the Commissioning takes place, followed by further steps after the execution, such as the elaboration of As Built projects and the Manuals of Use, Operation and Maintenance, as we will see in the following points.

In the strategic scope, any investment action in a health enterprise, whether a renovation or an expansion, should be the result of strategic planning,  since "healthcare buildings are living  organisms in constant adequacy to the strategy of the companies which occupy them''  (BROSS, 2013, p. 196).

The core of strategic planning is how to answer the following questions: What to do to achieve the objectives set by the institution? How to develop the steps, aiming to achieve the desired purpose? When to trigger actions in this direction? How to generate a favorable future with the objectives outlined?  (PEREIRA & GALVÃO, 2005,  p.73).

 The core of strategic planning is the first step towards the elaboration  of  a Master Plan, clearly establishing the reason for the existence of the healthcare facility, because all institutions must initially  have  a reason for being, an objective  or  an institutional  mission, which is  a kind of  operational summary of its nature and its central values, synthesized from the following points: what it does, why it does it, where it does it, for whom it does it, and how it does it (BADERMANN DE LEMOS, 2017, p. 9).

Also in the planning context, the hospital physical masterplan aims to diagnose the existing physical infrastructure and define its potential for use, for a long period, and should be flexible enough to adapt to the needs of future change, in a structured enough way for financial decisions to be made, also providing for the needs of reforms and  expansions according to the execution in phases, in order to organize circulations and connections with new works, demonstrating the sectorization of the units and the changes envisaged in each stage  (MENDES, 2018, p. 90).

In this context, the hospital physical masterplan becomes an indispensable part in the planning of the organization, being fundamental for the physical-functional reorganization of an existing hospital and, in the development of an architectural project of a new hospital, serving as a device for defining the types of interventions to be proposed, based on the existing capacity of the existing physical infrastructure and the perception of projections care demands (LEMOS,  2017).

The absence of medium and long-term planning will result in invisible pseudo savings, which will affect the future performance of the institution and, when it cannot be directly measured, for example, may prevent a new imaging diagnostic unit from being deployed in the hospital as a result of the recent implementation in the same location,  a warehouse and a laundry unit  (MADRIGANO, 2006, p. 9; CARVALHO, 2014, p. 65) .

Another essential item for planning and executing renovations and expansions in healthcare facilities is the document management of physical infrastructure. Particularly in health buildings, it is essential to keep projects constantly updated and compatible  (BITENCOURT & COSTEIRA, 2014, p. 46), and this care with the document management of the building is not only a good practice, but a matter of safety of the patient and users of the building.

The availability of the project on site is mandatory, as provided for in RDC No.  189/ANVISA, which establishes in Article 5th that " the owner must keep filed in conjunction with the project approved by Sanitary Surveillance in the topics related to complementary projects of structures and facilities, when it fits, as provided for in item 1.3 of the resolution" (ANVISA, RESOLUTION - RDC No. 189, 2003), summing up  this determination through RDC  No. 63 of 2011 in Article 23rd which says:

After having defined which works and renovations will take place in the healthcare facility with the respective physical-functional programs of all units/environments to be deployed and/or renovated, the institution can start the development of technical architectural and engineering projects safely  (MADRIGANO, 2006, p. 69). 
 

After defining the scope of the project, the feasibility studies for the project are  initiated. This is the phase when investors study its feasibility and make the estimative of costs, as noted by Nascimento (2015):

It is observed that the advantage of conducting a good feasibility study is clear when compared to the possible  costs  of  making changes during the phases of design and construction.  

Another point to be taken into account before the decision-making, during planning and designing phases, is related to hospital infection control, which can be carried out through studies of the risk control, aiming to integrate infection control and   epidemiology into the planning process of hospital infrastructure projects and  enabling, through this planning tool, the early mapping of risks to patients, as well  as  the identification of possible interruptions of essential services for patients (COUTO, R.C, 2009, p. 363).

Therefore, an inadequate analysis of the risks of dissemination of hospital infection will possibly result in failure in the definition of precautionary barriers  to control hospital infection in the area of  the work  and in its immediate  surroundings. The lack of financial resources for the correct sealing of passage areas, with the installation of sidings and other elements, can cause problems during the execution of the work, which can be avoided if such elements are foreseen since the phase of project development (PADULA, 2017).

Concomitantly with the planning of architectural and engineering projects, the elaboration of the contingency plan aims to map the risks involved in the execution of the work, as well as to define people who will be responsible for acting before, during and after its execution (1). 

According to Padula (2017), Ribeirão Preto Medical School's Hospital das Clínicas, University of São Paulo HCFMRP - USP, outlined a contingency plan encompassing several actions  to predict, avoid or mitigate risks, as well as to improve the understanding of all parties involved in the project of the work or renovation (PADULA, 2017).

It is observed that the strategy adopted  by HCFMRP-USP  gave  great importance  to the concepts about flows in the preparation and approval of projects of renovation works, in addition to considering the regulations and good practices adopted by the organization for the execution of the works and their respective phases; the obligations of the contracted company; the particularities for carrying  out works with the hospital in operation; greater understanding and commitment of the parties  involved,  during the execution of the work with regard to  the risks of hospital infection; better control of access of people in the work; improvement in signalization, hygiene, transportation, disposal of debris and  implementation  of  protective  barriers in the area under construction  (PADULA, 2017).

When carrying out works in functional hospitals, it will not always be possible to carry out construction or renovation activities as planned and within the desired time, which is why it is essential  to plan them in advance to reduce their interference in daily hospital  activities. It should be taken into account, in this process, that there are still few  companies specialized in hospital works, which is why it must be ensured that it is clearly transmitted to all the actors in the construction  all  information concerning hospital environment specific standards  and rules  (ANVISA, HOSPITAL SAFETY).

In this context, some ABNT rules already bring some points to be followed regarding good practices in the execution of hospital works, such as:

Based on these regulations, we highlight on Table 2, below, some of the main points  of attention related to protocols to be adopted during the execution of works and renovation in healthcare facilities and controlled environments:

The commissioning phase is the result of an entire process, which aims to ensure that the systems and components of a building or industrial plant comply with the requirements and operational needs of the customer, concerning its design, installation and testing of operation. 

(SGS, 2018).

In this context, ABNT standards provide for some points of attention to be followed regarding the commissioning of the healthcare facility physical infrastructure, such as:

It is observed that commissioning must be carried out in all phases of the enterprise, from  the project  phase to the delivery of the enterprise, being generally executed in the construction and assembly phase, thus avoiding failures and difficulties in the operation and maintenance of industrial plants after the complete installation  (SGS, 2018).

The quality of the technical documentation,  elaborated  during the phases of design and execution of the work, and its direction to elucidate issues related to the stages of conservation, use and maintenance, and the operation of the equipment in a systematized way, in the form of manuals, has been an instrument to improve communication in the process (ABNT, 2011).

With regard to As built project, NBR14645-3, of 12/2005, establishes the minimum requirements of which systems and building elements should be characterized throughout  the execution of the work and after its completion, so that the owner of the building can have the record of the systems that composes its physical infrastructure      (ABNT, 2005).

With regard to the building manuals, NBR 15575-1:2021 establishes it is up to the builder and developer to prepare the manual for the use, operation and maintenance of the building, also  following the requirements set out in ABNT NBR 14307, which details the warranty deadlines applicable to the various construction systems  (ABNT, 2021).

All this pack of documentation on the physical infrastructure of the hospital will serve as a basis for  future maintenance and conservation actions of  the  building, as well as for possible further interventions for renovations and expansions, assisting in the identification and mitigation of  risks, as well as saving time during the decision-making phases of projects  (BITENCOURT & COSTEIRA, 2014, p. 46).  

To achieve the overall objective of this research, we framed the following strategy:

•  To assess, through a bibliographic survey, what are the good practices adopted for planning and execution of  works in operational  hospitals;
•  To prepare a checklist with the main points of attention to be observed when planning works in healthcare facilities;
•  To validate the checklist with points of attention, after being verified with experts and companies that plan and carry out works at healthcare facilities;
•  To develop a risk matrix (2)  risks based on the checklist, demonstrating the actions to be  taken to prevent and mitigate negative  events during expansion and renovation works in healthcare facilities. 

(2) [...] the risk matrix is a tool that allows managers to measure, evaluate and order risk events that may affect the achievement of the objectives of the unit. [...] A risk matrix is a tool that qualitatively classifies impact and probability weights. [...] In general, risk events located in the quadrants defined as high risk and critical risk are generally considered indicative of the need for stricter 

During the bibliographic survey, we referred to references of planning and control of works, such as those from Aldo Dórea Mattos (MATTOS A. D., 2019), as well to Guia para Projetos de Áreas Limpas, by Brazilian Society of Contamination Control - SBCC  (SBCC: Working Group GT 4, 2012), which    addresses  the planning of works in controlled environments. Based on these literatures, the general scope of the checklist was elaborated.

During the literature review, we also consulted other authors and technical standards of ABNT that approach generally or specifically themes related to: Strategic Masterplan; Hospital Physical Masterplan; Building Management Documentation; Planning and Projects; Contingency Plan; Work Execution; Commissioning; As Built; and Manuals of Use, Operation and Maintenance; all topics related to the planning and  execution of works in healthcare facilities, as shown in Image  10.

We also highlight that regarding the Contingency Plan, we referred to bibliographic sources in the area of nursing and infectology, since this theme is transversal to health care activities and physical  infrastructure of healthcare facilities.

Therefore, once the macro themes of the check list were structured, we consulted in the bibliographic references the points considered to be more relevant to be observed in the act of planning and carrying out works in a functional hospital and, then, we sought advice from professionals working in the planning and/or execution of hospital works, in order to validate whether the themes identified as a point of attention are relevant.

One the checklist was validated, we framed a risk matrix, pointing out the impacts and actions to be carried out in order to mitigate or avoid damage, during the planning and execution of works, being consulted a specialist in risk management to guide the model adopted. 

As for the methodology adopted for the elaboration of the risk matrix, we used as a reference the Risk Matrix Guide of the Ministry of Planning, Development and Management; and as a scope of this matrix, the macro divisions proposed in the points of attention checklist. 

Based on the research carried out, it was found that, in order to plan a health enterprise, design it and, in particular, carry out works in operational hospitals, it is necessary to have a multidisciplinary team including engineers, architects, healthcare professionals, administrators, suppliers and other necessary actors.  

In addition, it was observed that, in order to obtain good results in the execution of works in a hospital environment, it is essential to have a well-organized health institution, with business  strategy, risk assessment, hospital physical master plan, infection control plan, contingency plan, building document records and well-designed architectural and engineering  projects.

Based on the macro steps defined, the checklist and the risk matrix were elaborated, with points of attention that must be assessed during the planning and execution phase of works in operational hospitals. Such points were validated with experts from the field; the checklist began at the macro stage of Strategic Masterplan, then we developed the risk matrix, highlighting  the relevance of the points of attention raised  (see Tables  2  and 3).

Based on the points of  attention exposed in  the checklist and the  risk matrix, it was observed that, without proper strategic planning for decision making, to know when and how to start an investment in renovation and expansion works in the hospital, with or without a risk management policy, with an established committee and with elaborate risk map, the decision to be taken (3)  becomes fragile and, consequently, the feasibility study of the inaccurate undertaking, which may cause conflicts and complications in the participation of the actors of the work, "[...] the future is uncertain and cloudy when senior management seems to start each day with a blank sheet of paper, without a planned continuity of actions"  (PEREIRA & GALVÃO, 2005, p. 74).

As for the hospital physical masterplan, it was verified that it is a very effective strategic tool for forecasting future investments in health organization works, which   contributes to mitigate risks in the institution's investments and stakeholders. From this      context, the main points of attention were  described in the  checklist  and in the risk matrix for the Hospital Physical Masterplan.

(3) The risk map should be continuously updated, as the project progresses, some risks can be eliminated with the completion of certain activities, other risks may be reduced and new risks may arise. Therefore, risk management is an activity that should be terminated only after the completion of projects" (BARRAL, 2021).

Thus, it is concluded that, while the costs of renovation are high, especially in long-time neglected buildings, and as there is usually little resources available, there is a willingness to spend first on aesthetic work, but it is essential that the most critical interventions are made before cosmetic work  (MENDES, 2018, p. 100) ,  so the hospital physical masterplan will be the basic tool to prevent resources from being applied in works that are actually pseudo savings.

As for the building management documentation, it was  noticed throughout the research  that  this should be the basis for  planning future works  in   a  hospital unit,  and that the projects as built and  the manual of use, operation and maintenance will directly impact both the management and technical decision-making and the phase of implementation of the business strategy. Thus, the inexistence of such physical  infrastructure documentation may  imply   the  following problems:  [...] "carry out operations in the various facilities without an accurate mapping of their distribution; [...] depend on the memory of former employees or exchange complete systems of facilities for lack of a correct survey of their distribution" (BITENCOURT & COSTEIRA, 2014, p. 46).

Once established what to do, why doing it, where to do it and for whom to do it,   comes the part of planning and elaborating architecture and engineering projects, which will fit the what to do, and should be developed within the technical premises of the various technical 

regulations of ABNT and  ANVISA, following the basic stages of project development: preliminary study; preliminary project; basic project; and  executive design. Such stages are defined in NBR16636 - Preparation and development of specialized technical services of architectural and urban projects.

With regard to the contingency plan, during the bibliographic review, it was identified as an essential macro step, since the planning phase serves to map the inherent risks, such as those related to hospital infection associated with the work being carried out. It is at this stage that decisions are made for possible relocations of patients, partial or total interruptions of care services.

As for the point of execution of works in functioning hospitals, little was found of specific engineering literature on the subject, being more addressed in the field of  nursing  and  infectious diseases,  besides in some specific norms of ABNT,  that deal with building systems of healthcare facilities and, occasionally,  in  other standards that deal with buildings in general.

 It was also verified, throughout the research, that the issues related to patient safety and hospital infection control are intrinsic to the work, so such  precautions do not affect only patients, but the system of the land. In addition, it was found that the main measures related during the execution of the work  are related to precautions related to construction sites.

As for the stages as built and manual of use, operation and maintenance, it was observed that  such documentation is essential for the final phase of the work, and should be carried out and updated throughout the execution of the work to maintain the traceability of what is being built and acquired.

With regard  to  commissioning, throughout the research, it was observed that it is not enough to build the  work, but it must also be tested and validated in order to be verified whether the construction was carried out according to the project requirements,   assessing  safety through tests and reports that will attest the building can be put into  use  and  operation.

All these steps aim to avoid economic damage to health organizations, material damage to buildings and its users and, consequently, damage to the health of patients, who seek hospital buildings to heal themselves.

The initial impression on the subject led us to believe it would be a simple task to sum it up, however when researching it more thoroughly, a range of essential information was observed that would not fit  in the few pages that an article supports,  especially when considering the multidisciplinary nature of  the theme.

It is notorious that, in hospitals, as well as in healthcare facilities in general, works are very common, and most of these places are always under renovation, in search of better serving the user getting more market share in the health market. Thus, it is recommended to all professionals involved in the planning and execution of works in hospitals that faithfully follow the provisions of the established technical standards, as well as seek to include, throughout the entire planning of such works, health professionals, patient safety teams, suppliers, and others hospital workers to avoid or minimize harm to patients and to the health organization as a whole.

ABNT. (12 de 2005). NBR14645-3 Elaboração do "como construído" (as built) para edificações - Parte 3: Locação topográfica e controle dimensional da obra - Procedimento.

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