‘A good refurbishment plan executed brilliantly is better than the best refurbishment plan executed badly’
Realising the need for timely renovation to keep hospitals in good health, government and private healthcare providers are investing on revamping and restoring old healthcare institutions. Dr Adheet S Gogate, Partner & Head, Philips Healthcare Transformation Services speaks on vital aspects to be considered in such projects, to Raelene Kambli
What are the important elements that need to be covered while revamping or restoring an old hospital?
There are usually three strategic questions to be clarified before undertaking any renovations or refurbishments:
First, it is critical to be very clear about the absolute necessity for refurbishment. Specifically, what is the goal in structural, configuration (number of beds, capacities etc.) and clinical/ operational terms? And what is the budget/ investment appetite for the effort? Establishing this clarity is the most important element – and often – the most neglected or unclear one. Hospital administrators need to establish a clear view of these questions before inviting planners or designers. Lack of clarity on these issues is the single most common reason for massive delays, cost overruns and generally unacceptable outcomes. Very often, many hospital administrators believe that poor business results are the result of infrastructure limitations and that refurbishment is a sure shot solution. In reality, the problem often lies elsewhere – in a poor business model, sub-optimal business models or quite simply poor management. Establishing that refurbishment is indeed the main solution to your business problems is absolutely important.
Second, it is important to establish how well these goals will be met. A key challenge with every refurbishment is the reality of limitations imposed by an older structure. It is absolutely important to have a clear understanding of what expectations may or may not be fulfilled by refurbishment of your older facility through a rigorous cost benefit analysis. In many hospitals in more mature markets, for instance, planners have established clear evaluation stage-gates to decide whether refurbishment should even be considered! In several cases, they’ve seen that refurbishment is not even justified because many buildings may not even be able to bear the shift to modern standards: issues such as very narrow passages, the inability of accommodate extensive cabling, ventilation, ducting and other engineering services may make benefits so small that refurbishment may not be warranted.
Thirdly, be clear on how you will do it. Will you shut the hospital? Will you do it in phases? What are the regulatory implications? Modern hospitals are highly complex and inter-dependent facilities; deciding on the execution plan requires careful thinking. On one hand, shut-down may impose a crushing financial burden. On the other hand, patient volumes drop dramatically when hospitals undergo refurbishment/ repairs, so the losses may be a lot less than expected. Keeping patients in a hospital with civil work can also be fairly traumatic and unsafe. In some cases, a total shut-down may be desirable – to address other non-facility related issues. On the other hand, phasing merely prolongs the pain and exposes the project to higher financial risks. Careful analysis is warranted. Finally, India has the most Byzantine and unpredictable building regulations and approvals systems. In planning any refurbishment, it is absolutely imperative to fully understand and be prepared for managing permissions and approvals. The best laid plans are worth nothing if they cannot meet regulatory requirements and withstand scrutiny!
What are the unique challenges in revamping heritage buildings?
Some problems are unique to heritage buildings. In general, with few exceptions, heritage buildings are not suitable for delivering complex acute care that modern hospitals are expected to deliver (especially very old ones). Their structures may impose major limitations (such as dragging cabling through stone walls; passage sizes unsuitable for stretchers and smooth patient movement etc). Several modern facilities – such as high-grade operating theatres with engineered ceilings and ICUs with air handling capabilities — are simply not possible. Then there is the matter of regulatory approvals.
It is hence important to maintain a pragmatic distinction between buildings that are merely old and those that are truly heritage structures (for historic or other reasons) and decide on refurbishment versus new development: caring for people must take precedence over keeping buildings simply for their age. Truly heritage structures have a very powerful historic rooting/ anchoring role. They have been refurbished – with strikingly beautiful and pleasing results – into administrative spaces, museums, or para-clinical spaces. Several examples of such renewals exist, both within India and worldwide.
Treated well, they, can enhance the most modern hospital! But not everyone may have that luxury, unfortunately.
What are the engineering areas that are involved in projects concerning refurbishment?
Structural and fire-safety integrity are major engineering challenges on older buildings. Modern safety codes are very demanding and bringing older buildings up to specifications can be a challenge. Other engineering considerations for refurbishment are no different from those for new hospitals. Modern buildings have a plethora of services: MEP, HVAC, IT, networking, transportation, logistics, services, others. Hospitals have their own special needs too – such as material transport engineering (e.g. via pneumatic chutes), high-speed movement, sterile movement and so on.
What are the challenges associated with such projects? Especially, if the hospital is functional while the revamp is on?
In my experience, the biggest challenges I have observed have occurred almost entirely due to insufficient attention to the three key strategic questions mentioned earlier. Some projects, for instance, get delayed for years, because the goal of the refurbishment, the boundary conditions, the priorities are unclear. There are few things in this space more challenging than undertaking a major renewal project if the goal is not clear.
Mention some learning lessons based on such projects.
Learning 1: Use refurbishment as a starting point of a performance transformation and not as an end in itself. The distance between being a good hospital and a great hospital is largely bridged by better management, operations and functional discipline: infrastructure renewal can take you only so far. Refurbishment may give you a nicer hospital but it won’t give you a better one: that is entirely dependent on the people, resources and processes within your walls! The biggest potential of a refurbishment is to create a new slate for transformations. Use the change to usher in fundamental changes: design simpler, patient friendly workflows, establish newer organisational structures to enable better care or even restructure your clinical departments for care, quality and safety.
Learning 2: A good refurbishment plan executed brilliantly is better than the best refurbishment plan executed badly. Be practical in your goals, accept that compromises and adjustments are inherent in refurbishments, brownfield expansions – or even in the most ambitious new projects! Learning 3: For real returns, invest in your people. Even as you invest in new property, plant and equipment, ensure you focus equally on people, processes and training to ensure you actually deliver improvements in patient care in your new infrastructure. Those elements matter more than anything else!
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