By Danny Gibson, MJ Medical Director
Italy is well known for its creative flair and contemporary design but when translated to healthcare, what part does equipment and technology have to play in the creation of new award winning hospitals and can the UK health system learn anything from the Italian approach?
In April this year, my colleagues and I from the Medical Architectural Research Units (MARU) planning buildings for health Masters Degree, went on a comparative health study tour of Italy. During the week long trip we visited some fantastic healthcare buildings, some of which were recently constructed, as well as some older buildings which provided by way of comparison examples of how progressive the new developments were.
As an internationally experienced healthcare planner and equipment consultant I had to date not worked within the Italian healthcare system, so I had no preconceived idea of how technology would be used. Sure I am familiar with Italian manufacturers of furniture and equipment, and yes I know that some of these manufacturers are known more for their low prices than perhaps their high quality. If I had been asked to guess, I probably would have expected their approach to technology to be similar to the UK. This assumption was relatively accurate; however, there are some real exceptions where certain types of technology are much more widespread or effectively used than in the UK.
Something you notice straight away when you visit one of the new facilities is that all the equipment and furniture is brand new. Whilst this should not be a surprise, the cynic in me expected the “back of house” equipment and furniture to be the more tired looking transfer equipment.
However, whilst transfer of existing furniture and equipment is considered at the business case stage, this is almost undertaken as a matter of courtesy rather than a real consideration. A healthy portion of any capital investment is earmarked for purchasing new equipment and furniture. At the Mestre Hospital in Venice for example, over 25% of the project value was ring fenced for equipment and furniture. The importance of having new equipment and furniture within a new building is high on the agenda for project teams and hospitals management.
They key difference from the UK is the development, security and importance of the equipment budget at the business case stage. A much more detailed approach is used to set a comprehensive equipment budget. Where the UK uses a largely unreliable broad brush approach to developing an equipment figure for the business case utilising Equipment Cost Allowance Guides (ECAG), Department Cost Allowance Guides (DCAG) and inflation measures as described in the latest Median Index of Public Sector Tender Prices (MIPS); the Italian business case takes the equipment strategy and schedules each item of equipment and develops a full equipment and furniture cost model at the business case stage, which is an approach most equipment planners have promoted within the UK.
This approach provides a budget foundation which is significantly more robust than that of the UK Capital Investment method. The benefit of scheduling each item of equipment and furniture is that it allows for whole life costing of equipment to be considered at the outset. The robustness of this information at the business case stage secures budget provision and certainty which is subsequently ring-fenced to protect it from any push for cost reduction following value engineering and affordability discussions.
With the hospitals themselves taking the vast majority of the risk with regard to equipment and furniture, the importance of the hospital project team and the design team working collaboratively becomes all the more important. Yet unlike the UK, of all facilities we visited in Italy only one had included the clinical users and/or patients in the design and functionality appraisal of the design solutions. Despite this, having walked around the facilities, there was little evidence that any of the facilities have suffered (in equipment and furniture terms) as a result.
One similarity of healthcare facilities in the UK and Italy is the widespread use of corridors as storage space. When visiting both old and new buildings such as the Meyer Children’s hospital which opened in 2007, I noted the corridor space routinely used for storage of just about any piece of spare equipment. It was unclear if this is a result of a healthcare cultural need to have things at hand or a lack of storage consideration during the design phase. Either way the issue of “corridor clutter” seems a is all too common in Italy and here in the UK.
The role of Guidance
Unlike the UK, Italy does not have centrally controlled mandatory guidance such as Health Technical Memorandums (HTM) or Health Building Notes (HBN). During their tendering process the criteria to measure competency of contractors and designers is heavily skewed towards previous design experience of Hospitals. The calibre of this previous experience, and the experience of the client team within the commissioning hospital, is considered enough of a measure of capability to ensure a clinically functional built environment.
Having the benefit of sharing this field trip with a diverse group of healthcare professionals, from estates directors, clinicians, engineers, architects and planners, what was clear to us all was that the new facilities certainly do not lack quality or inherent safety, yet they can be built and equipped for a fraction of a cost UK hospital. A consensus as to whether there is a link or not within our delegation was not reached, but this was clearly an area worthy of debate in the UK.
Innovation and Technology
One striking element of innovation in the Italian acute care sector is the use of robotics within the operating theatres. Every acute facility we visited used robotics to assist in laparoscopic (key-hole) surgery.
Surgeons at the Mestre Hospital in Venice are also pioneering robotics to provide mechanistic assistance in Neurosurgery. This world pioneering approach utilises a single arm robotic system for micro surgery and biopsy in an operating theatre environment. The robotic system can be used by the surgeon locally i.e. next to the patient, or remotely via a control console. The most interesting element of this technology is that it has been designed to function within an intra-operative MRI system, effectively allowing the robotic system within the bore of the MRI magnet whilst it undertakes an imaging sequence. This process provides a near real-time image of the area of the brain being operated on by a surgeon in the control room.
Continuing with the theme of robotics but on a slightly less grand but no less important scale, the use of FM robots or Automated Guided Vehicles (AGV) was used at a number of the acute facilities we visited.
The units provide automated portering services such as the collection, delivery and movement of supplies, laundry, waste and pharmacy consumables throughout the building. At the Versilia Hospital near Florence (which was designed in 1996 and opened in 2002), the use of robots has been widely used and tested. The older system at Versilia uses metal strips in the flooring to guide the robots to and from their destination. A more modern version at the Mestre Hospital utilises the hospitals integrated wireless network.
The AGV system is computer controlled and whilst the robots have a pre-determined schedule of activities each day, staff are able to remotely request an AGV to undertake a task from their local computer workstation anywhere in the hospital.
The AGV’s need unobstructed pathways. As such, their use and movement routes must be considered in detail and incorporated into the design from the outset. Designated AGV lifts are needed and must be integrated. Whilst the AGV’s have built in safety devices, (so they cannot crash into patients or walls etc.) keeping them separate from the patient, staff and visitor pathways is a detailed consideration. Any doors (including lifts) which the AGV’s encounter must either be held open on magnetic closers or have a level of integrated automation with the AGV units. This was successfully achieved at the hospitals we visited. It could almost be said that the automation provided by the AGV units was practically invisible to patients and visitors.
The system at Versilia is nearing the end of its lifecycle and the hospital intends to update the system to a wireless version. The Director of Estates at Versilia is delighted with the system and has undertaken a whole life value for money analysis of the use of AGV’s using the “actual” evidence based data he has collected. He reported that the results have shown clear value for money and cost savings for the operational management of the hospital. The ongoing maintenance of the AGV’s themselves has been low which helps to demonstrate the benefits in a clearly measurable way.
It is unlikely that these automated “robots” will completely replace the previous technology affectionately known as a “human porter”. Versilia Hospital which is low rise and consequently has a very long central hospital street, tried to harness the AGV system to move patients in beds. Although physically possible, this idea was abandoned following negative patient feedback. Patients complained of a lack of human interaction at a time when they needed reassurance, as well as the practicality issues, such as a patient returning from the bathroom to find a robot had taken the empty bed to the operating theatre!
Another innovation which is complementary to the AGV system is that of the “Telelift Unicar” system manufactured by Swisslog. The system was in use at most of the acute facilities we visited in Italy and acts much the same as a pneumatic tube system commonly used in the UK, however the main benefits of this system is that it can transport items weighing 10 kg (22 lbs) within various sized containers.
The system is not limited to just pathology samples but can also move patient records, documents, pharmaceuticals, sterile / non sterile supplies, drugs, multiple pathology samples and even hazardous waste. The system can reach speeds up to 1 meter/second and so is equivocal to that of a pneumatic system in terms of efficiency.
Much the same as the AGV system, the Unicar system is computer controlled enabling staff to designate the purpose and destination of a transport box at any time. The receiving stations are in a locked cupboard for security, and notification is made to the nurse base or a designated clinical workstation.
A final innovation worthy of note was seen at the Meyer Children’s Hospital. The Paediatric beds used in the wards were specially developed by the Meyer Hospital in partnership with a specialist Italian medical furniture manufacturer called Malvestio.
The problem faced by children’s hospitals is the age range they cater for, from babies to adolescents. Given this wide age and growth range, the need of varying bed sizes had been a constant problem. Meyer and Malvestio developed a bed which can electrically alter in length to suit the size of the patient. It of course means a number of varying size mattresses need to be stored locally; however when compared against the alternative of varying or unsuitable bed availability for the patient group, value for money was clearly demonstrated.
What about the future?
Perhaps one of the most common themes for each facility we visited, regardless of specialty or care level, was the lack of future planning or inherent flexibility for technology change or obsolescence. Although many of the buildings are designed to be extended in the future, the designers had given little thought to how clinical space could be adapted to incorporate new technology or clinical practice. Equally, the same lack of thought was evident when the question of how equipment, particularly large “big ticket” items, would be replaced at the end of their life cycle.
Although most of the facilities we visited were fairly new, several others had been operational for some time and it was these facilities which gave us the clearest insight into the consequence of not considering equipment replacement.
A good example to demonstrate this point was found at the European Institute of Oncology in Milan. The building, built in 1994 and extended in 1996, houses a significant number of large items of equipment, not least a Linear Accelerator (Linac) used for nuclear medicine. The Linac and the CT scanner (used for radiotherapy simulation), are now overdue for replacement. The concept of equipment replacement had not been considered during the design or construction, and whilst the building was originally constructed around the equipment (which is located in the basement) the removal of old and the installation of new equipment will be far from straightforward. With the CT and Linac located in the centre of the basement, significant building works including the removal of walls, structural columns and ceilings will need to be undertaken to allow the removal and replacement of these capital items. With such major works required, the Institute faces a difficult management conundrum when planning continuity of services. The Institute also has the desire to incorporate Tomotherapy in the future, but they admit they are severely constrained by the existing building envelope, which does not have the inherent infrastructure to easily adapt to new technology.
A similar example at the San Raffaele Hospital in Milan, where a large Cyclotron unit had to be replaced, involved the removal of a 2m thick lead lined wall with the hospital chapel above. Given that the San Raffaele hospital is a church run hospital, the management of this replacement activity had been extremely hard for the hospital to manage and they had admitted that they had not looked past initial operation when designing the facility.
Interestingly, the Mestre hospital which is rapidly moving into more complex interventional radiology and cutting edge clinical practice, had considered this element but only for the operating theatres which have a large internal plant space above the theatres, which allows for simplified reconfiguration of the theatres with minimal building alteration. The level of flexibility at Mestre comes at a price however, as the internal plant space takes a large portion of the ground floor internal area of the building, something inconceivable in a UK hospital where area is at a premium.
Having the opportunity to meet the designers of the new hospitals we visited, I decided to follow this line of questioning to see why or if this had been considered. The same answer came back to me each time, essentially future-proofing or the preparedness of the buildings to adapt to new technology or replace obsolete equipment had been overlooked, in the main, because it was not part of the clients brief for the facility.
The potential for inbuilt flexibility in the new buildings we visited had been a real missed opportunity for the hospital buildings. The lower construction costs mean extra space is affordable to projects in Italy which provides an affordable opportunity to incorporate flexibility for new technology into the design. I felt that the leading technology of today had been actively considered and incorporated, but paradoxically the technology of the future had been somewhat forgotten.
So what can the UK learn from this? Certainly that, when producing a business case, there are alternative and more robust methodologies for appraising the cost of equipment for a project, which can also offer the opportunity to introduce a whole life costing appraisal. Securing the equipment value in the business case and protecting it from value engineering and the inevitable affordability problems during the design phase will only support the creation of world class clinical service delivery to patients.
Whilst many will argue the plethora of “guidance” and mandatory codes in the UK provides a significant safeguard when designing a new healthcare facility, perhaps it could also be argued that the UK is over governed and controlled from the centre, providing a level of rigidity in design and operation which does not always complement or promote new innovation or alternative evidence based approaches to healthcare design and delivery.
Consideration of differing technologies to support FM services might be an emotive issue when it comes at the price of local employment, however when considered against the current government requirement to find long term efficiencies in the NHS, perhaps this is an avenue worth further consideration.
But maybe the biggest lesson to take away from Italy is that we should ensure our building design encompasses forward planning and flexibility. The building needs to have the capability to embrace new technology in reality as opposed to making it a lifeless or immeasurable requirement in an output specification, as the consequences of not doing so ultimately could prove the whole project be judged a failure in the long term. Without wanting to appear self serving, the appointment of an equipment consultant during the design phase would bring this forward thinking, future ready consideration to the design.
Danny Gibson is the technical director of MJ Medical and is an active health and equipment planning consultant supporting projects in UK and International health economies. Utilising over 15 years experience, Danny leads consultancy teams to provide evidence based advice to a spectrum of project types and care groups. His experience ranges from rural health clinics in Africa to super acute hospitals in the UK and Middle East.