Renovation and remodelling is unavoidable at a present day hospital. Be it a simple project of cosmetic changes in patient rooms or complex project like structural repairs at the OT; renovating and remodelling have become fairly common.
Nowadays, hospitals have budgets assigned for planned R&R activity every year. Hospitals have architects, planners, project officers, interior designers on their role. In fact, some hospitals have a whole construction project department to look after such activities. Today, hospitals realise the importance of periodic renovation and remodelling and thus it is an integral part of operations planning. Regular up-gradation of the facility results in better indoor environmental quality, improved patient safety, more efficient and flexible facilities, and higher patient and staff satisfaction.
Renovation rationalities
From increasing space to upgrading to the norms of NABH or JCI; there are many reasons for renovating and remodelling a hospital. Besides, hospitals are high traffic areas and are bound to wear and tear more quickly than any other infrastructure.
 “Meticulous planning, viability analysis, precise project planning and commissioning process are the basics of a good renovation plan.”Dr R Chandrashekhar Chief Architect, Central Design Bureau for Medical & Health Bldg.(CDB), Ministry of Health & Family Welfare, Govt.of India, New Delhi |
Dr R Chandrashekhar, Chief Architect, Central Design Bureau for Medical & Health Bldg.(CDB), Ministry of Health & Family Welfare, Govt of India, New Delhi says, “Hospitals must renovate to achieve optimisation of existing infrastructure which results in achieving functional excellence required for the healthcare needs of public and service provider.”
Many hospitals are housed in structures which were build 20 years ago, or brownfield projects that are housed in structures which were not intended for a hospital. In these scenarios, everyday operation may be limited due to unfixable flaws thus prompting the hospital management to renovate. “A hospital build 20 years ago may not have some specific requirements of present day like the JCI or NABH specifications. These are recent requirements. Thus, a facility needs to be upgraded accordingly,” explains Dr Nagendra Swamy President, & Chairman- Quality Council, Manipal Health Enterprises, Bangalore.
 “Most hospitals find it difficult to source money to finance the renovation. A cost benefit analysis then becomes necessary and renovations need to be budgeted.”Dr Alexander Kuruvilla President & CEO, Medica Synergie, Bangalore |
Additionally, periodic renovations help the growth of the hospitals. “A decade back most cities in India were serviced by small hospitals or nursing homes. Growth at these facilities; if any; was sporadic and unplanned. However, for optimal benefit and long-term success these facilities must go in for regular, planned, renovations,” opines Dr Alexander Kuruvilla, President & CEO, Medica Synergie, Bangalore.
Hospitals also need to renovate to accommodate evolving medical technologies. As treatment modalities develop, hospitals need to match the pace of these developments. “When the ‘patient density’ increases or the patient-to-space ratio turns adverse and when the existing structures provide insufficient space and support for latest clinical technology the hospital should plan for renovation and remodelling,” opines Mayank Madhani, Chief Operating Officer, Neev Group, Mumbai. Says Dr Kuruvilla, “One cannot just accommodate equipment wherever space is available but have to think about the larger picture and plan. If an ultrasound is to be bought you cannot just place it in a vacant room, in say the third floor, without thinking about how the patient would reach there.”
Above all today’s informed patients demand better facilities which is one of the main reasons to R&R which helps the hospitals to stay competitive within their market.
Renovation realities
Renovating may be inevitable for a hospital but it is easier said than done. Since hospitals are high traffic areas and a vital service they cannot shut shop for renovation. Closing down would also mean revenue loss. Thus most hospitals are renovated while operational. This creates many challenging situations for the hospital and the contractor. Besides, different areas of the hospital have their own challenges when it comes to renovation. “Shifting ward from one area to another unoccupied area may be simpler than shifting a radiology lab,” explains Swamy. “In case of a radiology lab there are room specifications, equipment specification and patient safety specifications, which need much time and consideration before shifting or taking up renovation,” he adds.
Added to this, patient flow and volume management becomes a challenge. Renovation projects also leaves the clinical staff stressed to manage better clinical outcomes in an environment of noise pollution, debris and dust.
Considerations
Weighing the pros and cons of renovating a hospital takes medical perspective, experience and creativity. Central to this decision-making process is the feasibility study. “Accurate analysis of existing infrastructure is the key to renovating any hospital,” says Dr Chandrashekhar. “Meticulous planning, viability analysis, precise project planning and commissioning process are the basics of good renovation plan,” he adds.
Quite simply put, a feasibility study helps establish if renovation of a hospital’s ward, lab, OT is possible, practical and whether it can meet the proposed needs. Not simply a cost-benefit analysis, a feasibility study evaluates technology needs and barriers, scheduling to complete a renovation project from start to finish, options and alternatives, and potential implications of decisions to the operations of the hospital. An inadequate analysis leads to a number of problems like hidden costs, increase in basic budget and delay in project completion. “Problems include studies being conducted by architects unfamiliar with renovation, inflated cost estimates for renovation, limited or no staff input, hidden costs not accounted for, and minimal consideration of patient impacts,” elaborates Dr Swamy. Feasibility analysis helps in meticulous planning for the renovation project.
Other than this judicious use of existing technology and resource is required. “Utilisation of existing technology and manpower is also important,” says Dr Chandrashekhar.
Capital for renovation if a financial barrier that needs to be be addressed with some thought. Hospital management should know the financial options available to them. Moreover, renovation is a capital cost and should be looked at as an investment. “Most hospitals find it difficult to source money to finance the renovation need,” says Kuruvilla “A cost benefit analysis then becomes necessary and renovations need to be budgeted,” he adds.
 “Renovation should be based on a well laid out plan of remodelling with a complete understanding of the effects of such a venture.” Ashok Kumar C Sr. Vice President, BGS Global Hospitals, Bangalore |
Says Ashok Kumar C, Senior Vice President, BGS Global Hospitals, “Renovation should be based on a well laid out plan of remodelling with a complete understanding of the effects of such a venture. The critical point in a hospital set-up is that every square inch of the hospital should be utilised for better patient care, good patient outcome and revenue generation. Cost benefit ratio of remodelling, how it affects the top-line revenues and EBITA should be worked out.”
Engaging the staff in the renovation project is also very important. “The management should hold meetings with doctors, clinical staff and all other employees to keep them involved as they would be the ones using the renovated facility.” says Dr Swamy.
Challenges
Working on a busy, fully functional hospital is not easy. There are various challenges like infection control, noise and vibration problems, disruptions to patients, staff, and visitors, emergencies, staging, parking etc,.
 “Site health, quality and safety along with hospital’s hygiene and infection free environment are always at the forefront of any phase of planning and execution.”Mayank Madhani Chief Operating Officer, Neev Group, Mumbai |
“Site health, quality and safety along with hospital’s hygiene and infection free environment are always at the forefront of any phase of planning and execution,” reveals Madhani. “Timely handover of the space, as planned, by the hospital authorities for renovation is a major challenge,” he adds.
Patients are central to a hospital function and the renovation projects should not inconvenience patients. While renovation happens patients are exposed to construction dust, they can develop nosocomial or hospital-associated infections which can be fatal. Planning for new construction or major renovation requires early consultation and collaboration to ensure that infection prevention is not only adhered to, but built into the design.
Noise and vibration control is another challenge. Work has to be done during normal daytime working hours so that patients have their rest time to recover. “There should be least disturbance caused to the patients during the process of renovation/ remodelling,” suggests Kumar. “Hospitals should ensure that there are adequate measures taken for infection control as well as measures for dust control. Areas where patients are housed should be adequately cordoned off. There should be redistribution of beds and measures to ensure that normal healthcare services are not hampered. The restructuring during the renovation should not affect patients and the housekeeping services – cleanliness in particular,” he adds.
Agreeing to this Madhani says, “Major challenges during hospital renovations are patient and visitors (traffic and movement) management, sequential phase wise planning for the renovation, keeping all the aspects/ departments of the hospital fully functional. Sound and noise decibels should be kept at a minimum as the other hospital facilities are functioning even during the renovation period.”
Adding to this Dr Chandrashekhar says, “Challenges while renovating hospitals are timely completion of project, operational vs redundant facility, vertical and horizontal circulation, structural stability and local regulations, resistance to change vs clash of culture.”
The challenges are in terms of financial, infrastructure, technology, and human resource, which are: accurate valuation of infrastructure, identification of upgradation needs, availability of trained manpower, resistance to change vs clash of culture, identification of training needs, upgradation of technical know-how, and managing change process.
Another challenge is to keep up with the present norms of building construction. “The latest construction technology like pre engineered building or light gauge steel frame structure (LGSF) are advised for adding additional facilities in existing structures. Also called PLUG and PLAY, it has different models like courtyard-in-fills, wrap-around, overroof or on gantries. For larger projects we must have meticulous planning of the complex, in terms of phase-wise demolition, and phase-wise construction, without interrupting even a single day of functioning of hospital,” explains Dr Chandrashekhar.
Public push
In India, both private and public sector is engaged in renovation and redevelopment activities. The government is making efforts to upgrade its facilities so that it will be able to match steps with the corporate sector. Recently, at the foundation stone laying ceremony for the redevelopment of Lady Hardinge Medical College, Health Union Minister of Health and Family Welfare, Ghulam Nabi Azad elaborated on government’s plan to augment healthcare services in India. In the 11th plan period 40,000 new constructions and renovations of health facilities were taken up under NRHM, out of which 20,000 have already been completed and the rest are under various stages of completion. To further strengthen tertiary healthcare delivery in the government sector, the Ministry also took up 19 state government owned medical colleges’ for upgradation under the Pradhan Mantri Swasthya Surakhsha Yojana. Six institutions have been completed and rest are likely to be completed by March-April 2013.
In 2013, the six new AIIMS and 19 upgraded institutions together would provide speciality and super-speciality care in all disciplines with a net addition of 11,390 beds covering 27 locations spread across the country.
Private projects
Recently, Manipal Hospital in Bangalore added a new renovated emergency care centre to the hospital. Max Super Specialty Hospital, Patparganj has launched five institutes within the hospital, each with a specialised area of focus. The newly launched institutes are the Max Institute of Cardiac Sciences, Max Institute of Neurosciences, Max Institute of Renal Sciences, Max Cancer Centre and Max Trauma Centre. Care Hospital, Hyderabad is also planning to double the bed capacity during next two years. The growth plans are mainly aimed at renovation of some of the existing hospitals, creation of additional capacity in existing cities, and upgrading infrastructure to elevate certain specialities to centres of excellence. Sir Ganga Ram Hospital, New Delhi has undertaken phased renovation of old blocks and will soon start construction of the new four blocks and a 11 storey car parking building in around five lakh sq feet area.
Fortis Healthcare, Executive Chairman, Malvinder Mohan Singh had said that Fortis will add 950 beds by March 2013, that will include three new hospitals and capacity addition at the existing facilities as part of a big expansion drive. Earlier in the year, Apollo Hospitals had said that it will add 500 beds by the end of this fiscal, taking the total bed strength of the group to over 9,000. “BGS Global Hospitals, Bangalore is currently remodelling the hospital to expand bed strength,” Kumar said.
Other corporate hospitals are also in expansion mode and taking up redevelopment and renovation projects.
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