Take it off-site [Healthcare Design]

Breaking out beyond smaller healthcare projects, modular construction is being sought out for its speed to market, quality control, and efficiency

WHEN IT COMES TO CAPITAL improvement projects, healthcare providers across the board are looking to reduce costs and shorten construction schedules while still seeking high-quality design and building materials. While this may seem like a lofty aspiration, modular building systems are stepping in to make it a reality.

Even just a decade ago, modular construction was seldom used in healthcare but today is picking up steam, with hospital owners turning to préfabrication for headwalls, bathrooms, or even an entire hospital. In fact, healthcare is currently the leading market sector utilizing modular construction at 49 percent, according to recent industry statistics. Furthermore, as healthcare organizations move toward more standardized environments and systematic approaches to care delivery, modular is proving to be a great fit.

For example, take the Miami Valley Hospital Heart and Orthopedic Center's bed tower, which opened in 2010. As the first U.S. hospital to extensively apply modular préfabrication, the Dayton, Ohio, hospital's patient rooms, exam rooms, singletoilet rooms, and patient-unit overhead utilities were ail built at assembly warehouses just miles from the site and then erected on-site. The modular units worked exceptionally well with the hospital's repetitive design, which incorporates 178 identical rooms on five identical floors.

"This degree of standardization provides flexibility, allowing functions to shift from floor to floor and reducing the need for patient transfers," explains Ryan Hullinger, principal at NBBJ (Columbus), which designed the project. "The inpatient room dimensions, infrastructure, and environmental attributes are designed to support the broadest possible range of patient types and clinical activities, making each room capable of flexing from low-acuity use for genAt eral med/surg functions to maximum-acuity use for cardiac ICU." The standardized components include identical room layouts so staff can quickly locate supplies and equipment, as well.

Another example is the four-story, 188,000-squarefoot Texas Health Harns Methodist Hospital in Fort Worth, Texas, where instead of coordinating and installing on-site the dozens of electrical outlets and medical gas and vacuum lines required for each of its headwalls, the hospital opted to have all of the headwalls prefabricated off-site. "The efficiency gained is astounding compared to building headwalls in place in the building, where each trade is getting in each other's way," says Winjie Tang Miao, president, Texas Health Harris Methodist Hospital Alliance.

In addition, Texas Health used modular components for the patient room bathrooms and portions of the HVAC and plumbing systems. "We expected less material waste and decreased total labor costs but were pleasantly surprised when the actual savings exceeded our expectations. In some cases, we had more than 40 percent savings in materials and 30 percent improvement in labor," Miao says.

Explaining how these cases of massive savings work, Huliinger says that off-site fabrication is a great way to bypass the intricate, painstaking process of organizing all the on-site routing and installation of complex building systems. "Regardless of the degree of coordination prior to construction, when highly complex architectural and engineering systems are conventionally installed in the field, the organization is often lost, wasting time and material," he says. "This isn't the case with our prefabricated approach, in which a coordinated layering of engineering systems is resolved digitally in BIM. The precise relationship between the BIM model and the fabricated components provides the building owner with a high-fidelity understanding of what's inside the walls and ceilings, which streamlines future modification."

In fact, savvy designers are even building future flexibility right into their modular designs, as was the case with the overhead MEP racks for Miami Valley, where linear "no fly zones" were left open inside each rack in order to accommodate future routing systems and provide easy access for maintenance.

Learning the ropes

Overall, NBBJ walked away with a number of lessons from the Miami Valley project. For one thing, the factory fabrication work proceeded along at such a clip that a second fabrication site had to be leased, since the contractors weren't ready to install the units in the field.

Applying this insight to its next modular project, a new OhioHealth Riverside Methodist Hospital Neuroscience Institute patient tower In Columbus (scheduled to open in 2015), NBBJ was better able to manage the project timeframe to avoid monopolizing the fabrication shop as a storage area. In addition to incorporating the same modular systems used for Miami Valley, the scope of prefabricated components was greatly expanded for OhioHealth to include exam rooms, perioperative spaces, holding bays, and toilet rooms.

"There's a long list of complex, multisystem components throughout the 410,000-square-foot tower being prefabricated, such as inpatient headwalls and the above-ceiling engineering racks in the inpatient wings and ORs," says Tim Fishking. principal, NBBJ.

Future potential

While modular construction touts an impressive list of benefits, there's still a certain stigma the method is struggling to overcome. "Historically, there have been some unfortunate associations with prefabricated architecture that was executed in a low-quality manner," Huliinger says. However, this is far from what's being produced today. Huliinger says that by standardizing components, designers and builders actually exert more control over the process, ensuring adherence to the design vision and creating greater aesthetic value.

Despite some design limitations (for example, required column work often doesn't allow for open spaces like atriums), the ability to finish these structures with just about any exterior-be it brick, stone, stucco, or glass-means today's modular buildings can look just like conventional architecture.

And as more modular healthcare projects are deployed, experts believe lingering doubts about the method will dissipate. Aspen Street Architects, Angels Camp, Calif., designed the Mercy Joplin replacement hospital in Joplin, Mo., relying heavily on modular construction. Founder David Hitchcock foresees a day when designing a freestanding clinic, hospital wing, or a critical access hospital will be similar to picking out a car, with all the features and amenities chosen by the end user. "I do believe that the field for modular healthcare construction is wide open at this time. There are just too many projects that could benefit from modular construction to believe that the concept could stagnate at this point." he says, hcd

the construction site of the OhioHealth Riverside Methodist Hospital Neuroscience Institute, a crane hoists MEP racks, two at a time, up to the inpatient floor. Workers then carefully pull the racks Into the building.

While modular construction touts an impressive list of benefits, there's still a certain stigma the method is struggling to overcome.

The first U.S. hospital to extensively utilize modular construction, Miami Valley Hospital Heart and Orthopedic Center in Dayton, Ohio, has prefabricated patient rooms, exams rooms, bathrooms, and patient-unit overhead utilities in its new bed tower.

Is prefab right for you?

Things to consider before pursuing modular construction

By Ryan Hullinger and Tim Fishking, NBBJ

When deciding whether to pursue prefabricated construction, everything comes back to return on investment. Préfabrication can reduce cost, save time, and improve quality, but it also entails an upfront premium in space, material, schedule, and labor-a premium that delivers value at scale, but only above a threshold that differs for each project. Here are some of the factors to consider:

Assembling innovative construction teams-The first and most important step is to understand the builder and its willingness to undertake préfabrication. Some builders are more innovation-focused, and some aren't. It requires a partnership among the client, architects, engineers, construction managers, and subcontractors who have the willingness and experience to think innovatively. Many state and federal contracts are awarded on low-bid alone, making it difficult to ensure that all the subcontractors are aligned in their willingness to work together on préfabrication. As a result, many more extensively prefabricated projects exist in the private sector.

Working with organized labor-The receptivity of the building trades must also be taken into account. Labor unions aren't categorically opposed to préfabrication, although multitrade modular construction does represent a change in "business as usual" and may require some education or negotiation to make this approach attractive. In some regions, a discussion with labor organizations may need to precede a determination of the viability the process.

Interfacing with regulatory agencies-The building codes and regulatory agencies that apply to a particular project can either encourage or discourage préfabrication. One approach is to develop positive relationships with building officials and inspectors by sharing the process with them during design and by promoting an open-door policy for them at the warehouse. Generally, inspectors will be appreciative of the opportunity to view the construction work in the shop, because there they can evaluate the assemblies much more thoroughly than is possible at the construction site.

Determining costs for off-site shop space and transport-Multitrade prefabricated construction requires a warehouse in which to assemble components prior to installation. The cheaper the warehouse, and the closer to the site, the more cost-effective préfabrication becomes. At Miami Valley Hospital, the NBBJ team was fortunate to obtain affordable warehouse space readily available in Dayton, Ohio, within seven miles of the hospital. On construction sites with available land, shop space can be temporarily erected on-site, but this also entails a cost premium.

Understanding contracts and insurance-Generally speaking, préfabrication doesn't affect legal liability, although contracts among the subcontractors may be structured a bit differently than they are on traditional construction projects. Mechanical contractors often already coordinate multiple trades; however, modular construction requires them to take responsibility for production, transport, and installation of the components, which is a different way of thinking about how subcontractors interface. Also, they must verify that the second site-the warehouse-is covered under their insurance policy.

Healthcare projects represent the perfect opportunity to consider préfabrication, because so many of their components are highly repeatable, highly complex, and have a high need for adaptability and upgrading. Carefully considering the cost and opportunity of the factors above can determine whether this approach is right for your project.

For a new OhioHealth Riverside Methodist Hospital Neuroscience Institute patient tower in Columbus (scheduled to open in 2015 and designed by NBBJ). overhead MEP racks are constructed inside a warehouse just miles from the site. The inpatient floor plates are curved, so the prefabricated racks are assembled on the shop floor to match the curvature of the tower. Toilet rooms for the OhioHealth project are also prefabricated in the same warehouse.

The modular units used at Miami Valley Hospital include a repetitive design in its 178 identical rooms on five identical floors.

Piece by piece at Parkland

While the nation's largest public healthcare project to be built in one phase can use modular only to a certain extent, the construction management team for Parkland Health and Hospital System's 2-million square-foot Dallas hospital regrets not incorporating more modular components. "If you do have a project that's conducive to a lot of repetition, don't be too conservative about how much modular can be used," says Walter Jones, senior vice president, facilities planning and development, Parkland Health and Hospital System.

For the $1.27 billion project tracking LEED Silver and scheduled to open in summer 2014, 862 bathroom pods were built by a contractor In a nearby warehouse and then transported to the site, as opposed to going with a modular company and a remote factory location. Whereas producing all these units in the field would have created some slight variation in the dimensions, by building the pods with a single workforce in an assembly plant, the consistency of construction is much higher. "Because I know exactly how each one was produced, this will be a great aid from a maintenance standpoint, as I have the exact template," Jones says.

Beyond the bathrooms, Parkland is using modular components for the adult patient room framework, headwalls, and rough-ins for the outlets and lines. For the patient tower, the main MEP ductwork, plumbing, fire protection, and cable trays were built in 20-foot-by-20-foot sections, raised up to the ceiling, and connected together.

"My construction manager is cautiously reluctant to put metrics on the benefits from a cost or scheduling standpoint, but quality-wise, it's already clear that we've gained a big advantage from the modular construction," Jones says.

Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at [email protected].