SAFHE/CEASA 2011 - Clarity Amid Confusion

Clarity amidst confusion A vision for Public Sector health facilities Infrastructure Norms and Standards in South Africa, driven by functional and clinical needs Richard Hussey

Background Prior to the election of democratic government, hospital planning was managed using the SA Hospital Norms, published under the Exchequer Act. The SAHNORM was rigidly managed by the Treasury Committee for Building Norms and Cost limits. Buildings were allocated area in departments according to a number of norm units – e.g. beds, examination rooms, meals served, etc.On the face of it, the system seemed logical and methodical…

AREA MANAGEMENT Area was rigidly managed. New hospital projects required a detailed analysis per SAHNORM category of the total area allowed for the intended purpose at the level of SAHNORM units, a calculation of existing area and any resulting shortfall. Norm Area Needed – Norm Area existing = Norm Area allowed (m²) If the existing area exceeded the Norm Area allowed for the existing Norm Units, then a formal condoning of this excess was required, or the excess was deducted from the Norm Area allowed for the new project.

FINANCIAL MANAGEMENT 1 Project budgets were rigidly managed using the simple equation: Norm Area allowed x Cost per Norm Unit = Project Budget (ZAR) Escalation were rigidly managed using Bureau for Economic Research indices - starting with projected indexes. Final allowable construction cost was capped by final indexes – 20-20 hindsight vision. Efficient management of the project budget during planning, design and documentation and construction was often to no avail as the final indexes for the tender month were adjusted after the fact by persons uninvolved in the project.

FINANCIAL MANAGEMENT 2 The approved budget was often exceeded at construction stage and design teams were frantically instructed to either effect cost cuts on a live construction project to prevent cost overruns, or to be penalised in their fees for those cost overruns. As a result, haphazard cuts in finish standards, eng. services or equipment were made to bring the project back within budget – all at the expense of service delivery.

APPLICATION OF SAHNORM 1The system had inherent shortcomings in its application. Aggregating building area irrespective of actual final application. As a result, clinical areas were weighted equally with storage, passages with operating theatres. Areas per norm unit were not managed per category and clinical service was often not given the elbow room it required. Clinical and functional space was not prescribed in allowed norm area – only the gross allowable maximum area. Rooms were built too small, inflexible in design and to a low standard of finishes to ensure that the guillotine of final cost index was not exceeded.

APPLICATION OF SAHNORM 2Ultimately this compromised service delivery and increased maintenance costs. The Committee for Building Norms and Cost Limits cared little about what happened above the line. Funding of departments within projects was pooled to provide a single bottom line. Accountants in committee ruled on the design variables (e.g. add-on costs for special foundations) with little or no knowledge of the real cost drivers. TCBNCL cared little for health outcomes - it simplistically counted square metres and Rands. Buildings could be planned as they wished and area applied at will, with cross-subsidising of area and cost, providing Approved Norm Area and Final Norm Cost were not exceeded.

THE SAHNORM IS DEAD!The Public Finance Management Act repealed the Exchequer Act. SAHNORM and its entire management structure disappeared. Responsibility for managing area and cost norms was passed about between unwilling government departments. Finally, the National Department of Works was dumped with the responsibility of setting standards – which it then proceeded to conveniently forget about (where health facilities were concerned, that is.)

THE SAHNORM IS DEAD…! Without a similar subsequent structure to manage complex health infrastructure planning, a haphazard methodology of managing health facility norms and standards came about. Provinces planned new projects without limits on area or cost. Some continued to apply SAHNORM as a guide, others ignored it. Some applied the R158 regulations instead, despite these having been set up as “bare bones minimum” requirements to licence private facilities, R158 is not the desirable clinical or functional space necessary to deliver a quality public health service.

AND THEY’RE OFF…! 1With the demise of the SAHNORM, the reins of the horse were dropped and the horse leapt forward with gusto! There was a real need for improved access to health care and a political imperative to delivery to communities that had been without equal health care for decades. Driven by pressure to deliver and confused by other interests both legitimate and less than legitimate, the capital cost of building health facilities increased dramatically.The horse was bolting out of control…

AND THEY’RE OFF…! 2A ‘free-for-all’ came about, Project teams were able to pump up the cost by applying unrealistically high specifications. (They earned much higher fees for far less work and nobody was complaining.) There were no measures in place to manage and / or moderate political imperatives. To aggravate the situation, a critical shortage of skills during the transformation from a racially skewed administration resulted in many middle managers simply not managing – some because they didn’t know any better and others because they just wanted to stay below the radar until they could retire. When they did retire, another part of the corporate memory disappeared with them and the knowledge base atrophied even further.

AND THEY’RE OFF…! 3This inequity of standards stifled the efforts of health planners to provide equitable access to health care. Service delivery was seriously compromised. Proper service planning was inhibited by rapidly depleting infrastructure budgets. Instead of being able to build 10 hospitals at R1,5m per bed, provinces could only build 5 at R3,0m per bed. Ignorance, ill-informed decision-making, image-seeking and infectious greed was robbing expectant mothers of clinical care and new-born babies of incubators.A new nationally applicable system of area standards and cost management was desperately needed to replace the extinct SAHNORM.

IT HISTORY 101Let’s look at what life was like when SAHNORM was set up … in1984 IBM has invented a small computer– the Personal Computer. A young man called David Gates and another geek partner have developed an operating system that will allow this new machine to work. The operating system is written on a magnetic disk that gets the name “floppy disk” from the inability of the thin magnetic plastic medium to support itself. This requires the floppy disk to be contained in a cardboard envelope with a slot in the cardboard – a “Window” ? The new floppy disk contains 360k of data written on one side and there are TWO of them in the computer. It is rumoured in the industry that very soon a disk with data on BOTH sides will be available – 720k on a single disk!

IT HISTORY 102Let’s fast forward to 2011… The floppy disk is a quaint oddity of history. Portable data memory media is not measured in kilobytes, nor megabytes, nor gigabytes – it is measured in Terrabytes. (If in 1984 you had given every human on this earth a single 360k floppy disk, the total data content of all those floppies would be 720Tb) Direct application of a 1984 SAHNORM is as appropriate today as using floppy disks!

THE TECHNOLOGY TREADMILL 1Technology is literally driving society today. The average car today has more computing power on board than the first mission to the moon in 1969. Instead of taking your motorcar to a mechanic for a tune-up once every six months, you are blissfully oblivious to the fact that your car’s computer is adjusting valve timing, fuel to air ratio and ignition timing 10 - 25 times… …every second !

THE TECHNOLOGY TREADMILL 2Technology does more in less time Current technology on every laptop enables skilled planners and professionals to perform complex and laborious calculations in a matter of seconds. Ove Arup mailed punch cards by parcel post to their London office to calculate the structure of the roof of the Sydney Opera House on an IBM mainframe computer. The mainframe took 12 hrs 42 min to calculate a single arched beam. Arup staff recently ran that same calculation using software presently available on every structural engineer’s laptop… The result was produced in 3 seconds.

THE TECHNOLOGY TREADMILL 3Technology exists today to totally self-control an aircraft to the extent that it can: start up, taxi to the runway, take off, fly a complete mission, navigate to a destination airfield and then land…all without any direct intervention by a human.

THE TECHNOLOGY TREADMILL 4 Advances in medical technology have shown similar trends and the rate of growth in this knowledge is increasing. Magnetic Resonance Imaging, PET scanners, Gamma knife surgery, Radiation Oncology Linear Accelerators… the list goes on. How do we curb the excessive space and cost overruns of the past decade? How do we catch up twenty, thirty even forty years of technology? The problem of technology also provides the answer. Using commonly available spreadsheet software, we have the tools to perform detailed analysis and management of a lot of information.Let us use this technology to eat this elephant… …in byte-sized portions!

AREA MANAGEMENT Managing area is a proven manner of positively influencing capital costs. Dept of Public Works Office Standards – Govt Gazette 27985 of 2 September 2005. This space planning logic used need as the driver for space – not merely averaging previous practice. If you don’t build what you don’t need, you don’t waste money.After all, SAHNORM methodology worked in theory, it was only the practical application was flawed, wasn’t it…?

“FIT FOR PURPOSE”SPACE DESIGNForm forever follows function – Louis Sullivan, Architect.Let us look at a very simple space for example – the space to park a motorcar. “Traditional” space guidelines such as say a parking garage is 3m wide and 6m long =18 square metres. (Neufert, AJ Metric) This space will fit any motor car, except a Rolls Royce Silver Spirit at 6,05m long. A good standard, one might think, at a 99,999 percentile accommodation. South African National Building Regulations requirements for a public parking space are 2,5x5,5m = 13.75m² - a 24% reduction in this requirement. Is this also a good standard? Which of the two is appropriate?

“FIT FOR PURPOSE” SPACEDESIGN 1Form forever follows function – Louis Sullivan, Architect. Users of public parking areas know how frustrating and costly it is to return to your car to find that your car door has small vertical dents in the paintwork due to your neighbour opening their car door just a little too far, causing their open door to bang against your car. This experience, therefore, tells one that the ergonomics of entering and exiting the car were not taken into account in sizing that public parking space. Also, there is an increase in the number of two-door coupés such as a BMW C1, Toyota Yaris or a Volkswagen Beetle. Doors on coupés are wider in order to give access to the rear seats and so the space required to fully open the two-door is wider than that of a four-door family sedan.

“FIT FOR PURPOSE” SPACEDESIGN 2Form forever follows function – Louis Sullivan, Architect. Present day cars are somewhat smaller than the vehicles that gave rise to the standards of the 1950’s, 60’s and 70’s. Yet these reference space standards still are applied religiously half a century later.

“FIT FOR PURPOSE” SPACEDESIGN 3Form forever follows function – Louis Sullivan, Architect. ‘Fit for purpose’ design for today’s requirements would indicate that parking spaces should be shorter and wider to allow proper ergonomic exiting from both sides of a two door vehicle. Theoretically in public parking spaces, such ergonomic space can be shared – providing drivers park their cars in the centre of the space. (We all know how many times this does not happen.) Between walls though, wider space is definitely required for effective ergonomics, and shorter space is possible for cost reduction to balance these spatial requirements.

ESCALATING COMPLEXITYTraditional logic for a simple space such as a garage is not reliable enough to apply directly to current requirements. Do we simply extrapolate this same deficient historical space requirement logic to a far more complex space such as an operating theatre? comatose patient on a life support system, several clinical staff members simultaneous activities complex sterile medical equip. with service umbilicals instrument trolleys and tables…?

 I contend that one has a far more exhaustive space requirement analysis to do in order to come up with a present day ‘fit for purpose’ standard. Anything less is just a ‘we’ll make do’ solution.Is this how we want to invest scarce capital in health facilities?

CLARITY IN DEFINING NEEDSFirst we shape our buildings, then our buildings shape us. [Winston Churchill 1943] Users have an inherent problem in communicating their clinical needs to physical planners. More often than most, they will introduce as their need a copy of what they were trained in, what they currently work in or something they saw somewhere else. This is in fact the solution offered to another user’s needs, not an analysis of their own needs.

CLARITY IN DEFINING NEEDS“First we shape our buildings, then they shape us, then we shape them again - ad infinitum” [Stewart Brand, 1994] writer, Editor of Whole Earth Catalogue Perpetuation of this solution-based needs definition for clinical and functional spaces is as appropriate as applying Neufert’s 1960 solution for a parking garage to house Sir Alec Issigonis 1959 design for the Mini. We need to be able to define the user’s requirements more fundamentally from the actual need for space.A proven methodology in determining this comprehensive analysis of need is the application of six questions…

Six QuestionsWHAT? HOW? WHO? WHERE? WHEN? WITH? Users focus their needs establishment by answering the questions about the activities they perform in the spaces they need. This narrative is then interpreted by physical planners into three-dimensional space requirements that are sufficient to provide for the activities where they occur. I’ll refer to the information output of this process as the WHoW.

WHAT CAN I DERIVE FROMWHoW?Question Aspect of needWHAT? ACTIVITIES TO BE ACCOMMODATEDHOW? METHODOLOGYWHO? PEOPLE INVOLVEDWHERE? LOCATIONWHEN? TIME SIGNATURE + PROCESS ORDERWITH? LINKS, CO-PROCESSES CO-LOCATIONS

Service solution comparison =standards comparison 1 The rendering of a health service is tailored around the WHoW. Different countries use different methodologies for every procedure and so the WHoW differs. Simple bed space, for example, is defined by the processes and methodologies appropriate to that country. In some countries, much use is made of mobile patient lifting apparatus, the bed- head space is increased to permit this apparatus to be brought to either side of the bed. Eliminate the use of mobile lifting apparatus, or merely turn the bed slightly and the lifting apparatus can be used efficiently without requiring this multiple permanent free space for a very occasional process. Remaining within functional limits, less space = less cost.

Service solution comparison =standards comparison 2 It is the differences in WHoW that result in other health facility norms and standards having varying degrees of appropriateness to the South African situation. This does not mean that we have to rethink absolutely everything from scratch, but we have to take due cognisance of the matching WHoW when reviewing any standard from anywhere else.

Service solution comparison =standards comparison 3 Having compared the operational narrative and the equipment list and the services and the personnel and the processes, we are left with four choices to make around other standards presented for comparison; Adopt WHoW aligns perfectly and no change is needed. Adapt WHoW is very similar, slight changes easily made. Assimilate WHoW is not that similar, but some aspects are easily incorporated in our standard. Annihilate WHoW is so different that nothing is transferable.Mere adoption of isolated external standards constitutes a fifth unacceptable path – abdicate.

BOTTOM-UP BUILDING BLOCKS This bottom-up clinical / functional needs analysis is the proposed knowledge foundation for a new national Health Facility Norms and Standards system. It provides clarity around the problem of defining what the user needs in small enough bites of information to enable them to focus on what they do. It enables physical infrastructure planners to similarly extract understanding of the needs and to translate this need into building functional units so the user can do what they do. With appropriate yardsticks available from defined clinical area standards and ‘fit for purpose’ standards for associated support space, the other drivers of design sprawl can easily be addressed - because they become glaringly obvious.

PIAZZAS, PASSAGES ANDPARK-OFF PLACES Circulation Space and Waiting Space can be managed by a defined allowance over and above the clinical / functional space standards. With the SAHNORM, add-on space allowance was contentious and never enough to provide for proper circulation space management. This meant that circulation space was often provided by stealing from functional space. By separately measuring circulation and similar general space under Core Space allowance, planners are given the ability to apply this within the building functional units and between units. Because it is separately measured, this space is separately managed and any overprovision becomes obvious.

MEASUREMENT IN LOCATIONS The standard methodology of measuring Bills of Quantities as used by South African Quantity Surveyors allows the software used to be set up to measure by localities. It costs no more and provides much more useful information to the user. For example, the cost of providing an additional operating theatre can be easily determined as the net effect on the Operating Department building functional unit can be measured, without having to search for snippets of data from the whole health facility. It is therefore proposed that this method be mandated as an extension of the space standard management methodology right through into the final building on all public health facilities.

ELEMENTAL METHODOLOGY Further to measurement by location, elemental measurement methodology can be used when calculating building costs. This method will provide both user and implementing agent with the tool to better manage the cost of construction by identifying the main cost drivers of any particular design. This will also permit effective analysis and decision-making when it comes to choices of materials, increasing or decreasing ceiling heights and comparing construction methods such as load- bearing brickwork against column and slab. It is also proposed that measuring by building elements be mandated for health sector building cost management.

SO,HOW DOES THIS ALLWORK TOGETHER…?

AREA MANAGEMENT WHoW will be developed from the clinical and functional needs for each individual building functional unit for every level of health facility (as defined by the National Health Council, using the Feb 2007 version as departure framework.) The narrative will help to clarify differences in approach and needs, where such differences are applicable. A translation table will allow the user and the planner to define where the space is appropriately required, according to the building’s functional units or blocks.

AREA MANAGEMENT Functional / clinical space (e.g. bed, theatre, delivery room) will form the Norm Unit for defining the required nett floor space. Support Space for associated rooms and Core Space for circulation / shared facilities are managed by separate allowances on top of the Clinical Space. Using methods similar to the Office Norms, each schedule of accommodation will contain clinical / functional area standards, with Support Space allocated as a variable factor over and above the clinical / functional space to allow for any slight variances per level of care or per clinical discipline. Core Space will be a fixed allowance as it is pooled for the whole facility. Because all of these are defined in nett clear floor area, a final fixed allowance for structural elements is needed.

AREA MANAGEMENT The norm unit area standard and the other allowances will aggregate upwards into a total allowable area standard per building functional unit – e.g. wards / nursing units, radiology departments. All functional areas will be allocated area standards based on their WHoW – e.g. Nursing Units for medical, surgical, orthopaedic, ICU / High Care, step-down, maternity, psychiatric, TB…The nett effect is that every functional unit in any health facility will be defined by an area standard per clinical space, variable area for support spaces and a fixed allowance for core space and structural space. This will easily allow detailed total area analysis as designed against area required per functional unit. The functional units will roll up into a total area per health facility. Clinical or functional need will no longer cross-subsidise any other space.

ROOM REQUIREMENTS The Area Standards will be refined and supported by detailed room requirements, which in turn are supported by documented building standards and materials, in order to fully articulate user requirements. These will provide the user with a detailed drawing of what to expect in the final product. The detailed room requirements will require regular revision within the health sector in order to accommodate any technological or functional changes to the WHoW.

COST MANAGEMENT 1 From a cost perspective, the cost of building health facilities will be analysed per building functional unit and per level of care. This will enable Departments of Health to arrive at a cost per square meter range per building functional unit. The cost range will take into account such factors as the province concerned, inland / coastal variations, and distance from materials markets, etc. This cost management tool will provide the tools necessary to budget forwards, to manage budget during design / documentation and to feed back real project information from every project into regularly refining the cost range for future projects.

COST MANAGEMENT 2 Initial breakdown of area studies indicate individual building functional units vary between 1-5 percent of the total area of a district or regional hospital. The proposed system enables effective management of area and cost per building functional unit to provide the public health sector with the detail analysis necessary to manage service definition and service delivery standards. It will provide the framework necessary to ensure efficiency of planning, design and documentation, using simple-to-operate, spreadsheet-based tools.

COST MANAGEMENT 3 The proposed system relies on efficiency of knowledge management, co-operation between client, implementing agents and professional service providers – particularly Quantity Surveyors…! Contracting models should not be affected at all. Data from various contracts can be directly integrated into the database that derives the cost model per building functional unit to broaden the number of records on which the cost range per building functional unit is founded.

INVITATIONI invite you to take up the challenge and to work with my team in this endeavour to establish a sound, solid and sustainable system of standards that will enable us to hand over to our children and grandchildren effective and efficient health facilities, built on the basis of the right thing in the right place at the right place at the right time and at the right cost... Thank you for your attention and time.

Enquiries: Richard Hussey Director: Facilities + Planning National Department of Health Private Bag X828 Pretoria 0001 E-mail: Hussey @ health.gov.za Work: 012 395 8284 Cell: 078 456 5267

SAFHE/CEASA 2011 - Clarity Amid Confusion

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SAFHE/CEASA 2011 - Clarity Amid Confusion — Presentation Transcript

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