The utility systems hidden above ceilings, in walls, and in utility closets provide the heating, ventilating, air conditioning, lighting, electric power, medical gases, and fire protection necessary to deliver effective patient care in a health care facility. Together, these systems represent the facility infrastructure.

Many health care facilities with buildings built in the 50s and 60s are in good physical condition, with infrastructure systems that have been replaced and upgraded several times in the life of the building. Clients will sometimes refer to the most recent construction as the ¿new building¿ or ¿new wing.¿ These ¿new buildings¿ are often 15 to 20 years old. Well-constructed buildings can remain viable well beyond the expected life of the infrastructure systems. Major equipment and systems are often kept operational and serviceable beyond the expected useful life due in large part to good maintenance, repairs where necessary, and the pressure to just keep it running.

At some point in the life of a facility, there comes a realization that infrastructure upgrades are necessary. This awareness is usually triggered by a facility upgrade or master plan and sometimes by a major equipment failure that raises questions regarding system reliability. Older systems often do not meet current performance requirements due to changes in codes, medical equipment requirements, and changes in use. There are many sound reasons to take a proactive approach to managing the regeneration of facility infrastructure systems. Infrastructure represents a significant, long-term investment. A reactive approach often results in increased risk, potential lost revenue, potentially high emergency repair cost, high operating cost, and increased maintenance cost.

Managing the infrastructure in a reactive mode often results in poor value and compromised solutions. Replacing a failed system or piece of major equipment with a similar size or type is generally not the best value, but often the only alternative in an emergency repair or unplanned replacement. Over time, central systems often start to become decentralized reducing reliability and increasing maintenance and operating cost.

Infrastructure often takes a back seat to architectural master planning when new construction or renovation projects are in the early stages of development. Infrastructure deficiencies are often revealed after capital has been allocated and expectations have been set. Often, this is due to minimal or late involvement by the engineering and facilities team. One way to avoid infrastructure surprises is to develop an infrastructure master plan. The infrastructure master plan should be integrated with the facility master plan to address infrastructure deficiencies and integrate the solutions.

A Better Plan

Not all infrastructure plans are created equal. Almost every health care facility has a bookcase, usually somewhere in the facilities department, with volumes of strategic plans, master plans, and engineering studies. Often the infrastructure recommendations and conclusions are only partially implemented or never funded. These studies become the starting point for the next study or master plan making it just a little easier for the next consultant to likely arrive at similar conclusions, describing how things have further deteriorated since the previous study was completed. A new approach is necessary.

A facility infrastructure plan creates opportunities to reduce upgrade cost through consolidation, technology upgrades, and risk management.

What separates an effective infrastructure plan, that ultimately results in improvements, from the previous reports gathering dust in the bookcase?

  • Clear understanding of the client¿s objectives
  • Conceptual solutions
  • Integrated strategic approach
  • Comprehensive assessment
  • Realistic capital plan
  • Flexible strategies
  • Quantify risk
  • Prioritize

Air-handling units generally have a life expectancy of 15 to 20 years. The reliability and performance of the air delivery systems have a significant impact on patient comfort and indoor air quality. Innovative solutions are often necessary to minimize downtime. This project included the consolidation of several air-handling units into a single system and a conversion from constant volume air delivery to variable air volume. The system was also converted from 100% outdoor air to return air, reducing energy and maintenance cost.

Client Objectives

A good infrastructure plan starts with a clear understanding of the client¿s objectives. Engineers need to ask the right questions and, more importantly, listen to the responses. Clients can have very different requirements and criteria for decisions regarding infrastructure systems. The ability of the staff to manage and maintain the existing systems, long- and short-range strategic plans, potential new construction or renovation projects, and available capital are some examples of criteria that factor into understanding the client¿s objectives.

Some clients are positioned to implement an aggressive plan to minimize risk, reduce operating cost, and invest in the infrastructure. Many, however, are struggling to reduce capital and offset operating losses. These clients need an infrastructure plan that can logically manage infrastructure investment to minimize risk and delay major expenditures.

Conceptual Solutions

Solutions are at the heart of a good plan. Solutions represent the ideas that translate into capital requirements, phasing plans, and master planning implications. Conceptual-level solutions do not represent complete engineering designs but well thought-out engineering concepts. The concepts need to be explored, evaluated, and developed to the level necessary to mitigate significant risk regarding cost and constructability.

Experience and expertise plays a major role in prioritizing the effort necessary to develop solutions. Knowing which details are important and which details can be deferred until later is not easily explained, and each situation is different. Less obvious issues might include the availability of emergency power to serve a new load or the ability of the structure to support a new piece of equipment. This phase generally doesn¿t address finding the exact pipe size or knowing exactly how many tons of cooling might be required. What this phase should do is explore opportunities to consolidate systems, simplify, correct deficiencies, reduce operating cost, and improve reliability.

Renovating infrastructure systems in occupied facilities presents its own challenges. Keeping systems operational and in service with minimal disruption to patients and staff often plays a significant role in developing solutions. Often, temporary measures must be implemented to facilitate the upgrades. A comprehensive approach to the proposed solutions includes phasing, planning, and capital to accomplish all the necessary steps.

Integrating infrastructure projects with building projects has many benefits. Invasive type projects that require extensive disruptions are, if possible, best implemented as part of building upgrades. Examples include lighting upgrades, vav retrofits, and electrical distribution upgrades.

This process can often be expanded to incorporate existing system upgrades such as converting constant volume pumping to variable volume as part of a chilled-water plant upgrade.

Strategic Approach

All the recommendations, planning, and solutions should be developed in the context of a long-term facility master plan. The long-term plan for the facility can have a dramatic impact on recommendations. Strategic plans seem to have a short shelf life these days with all the changes in health care technology and the financial struggles. The best available information will result in a plan that more closely meets the identified needs and can respond to the changes. There are often opportunities to overlap solutions and solve multiple issues, such as insufficient capacity or improved reliability, that will only be realized if the long-term facility plan is integrated into the infrastructure plan.

Comprehensive Assessment

When it comes to site assessment, examining the design drawings and walking through the facility are simply not enough. A comprehensive assessment of the facility includes interviews with key facilities personnel and often requires measurements to help understand and quantify complex problems. It is not possible to understand the system performance issues during a site visit. The dynamic nature of systems does not reveal itself in a day or a week. Often the seasonal changes bring hidden performance issues that only an operator who has lived with the nuances of a particular system will know. A comprehensive assessment can only be achieved by the piecing together of design drawings, site observations, field experience, and operator input. Sometimes additional investigation is warranted in the form of balancing or electrical measurements to develop solutions for more complex problems. Clients frequently ask, ¿Do I really need to replace a piece of equipment or a system because it is old?¿ Sometimes the answer is yes, and sometimes no. Being old is not sufficient reason to replace equipment. Older equipment is sometimes more durable and reliable than newer equipment and should be rebuilt or left in service.

On the other hand, old equipment might have issues related to being old ¿ such as difficulty finding replacement parts, inefficiency, or normal wear and tear ¿ that makes replacing the equipment more economical. Sometimes new equipment may need to be replaced, which can raise even more questions. The new equipment might have been installed as a reactive solution to a problem, yet it may not fit into the long-term plan.

A Realistic Capital Plan

The infrastructure capital plan represents the infrastructure work necessary to meet the strategic objectives. The capital plan should be flexible, reasonably conservative, inclusive, and integrated with the strategic plan. The capital plan is the business plan with which decisions can be made concerning capital allocations. A good plan answers the questions: ¿What do I absolutely need to fund this year, next year, and for the length of the plan? What¿s the risk of doing nothing? Are cost savings available by dealing with a project strategically vs. an emergency repair? What is the return on investment?¿

The estimates included in the plan must be conservative, yet realistic. The estimates also need to be comprehensive and include not only the construction cost but also the related project costs such as design fees, temporary measures, inflation if projecting out over several years, and financing cost if appropriate. Related cost should also be considered such as general construction and commissioning. Contingency funds should be set aside to fund the likely unexpected items that can only be uncovered in a detailed engineering design. Contingency will vary with the types of projects and the technical and construction complexity. The capital plan should also identify potential cost savings available from increased energy efficiency, reduced maintenance cost, or alternative energy sources. Often utility rebates are available to help offset the cost of implementing projects that result in reduced energy consumption.

Flexibility and Risk

The dynamic nature of health care is having significant impact on facilities. Systems need the ability to be modified to adapt to changing requirements without complete replacement. System flexibility does not come without a cost, but often the incremental premium is small when compared to the potential benefits. Incorporating flexibility into the infrastructure design or renovation requires planning and experience. Sometimes it means leaving a little extra space or extra capacity, or it could be a modular approach that can accommodate more stringent performance requirements that might be required in the future.

Risk can be difficult to quantify, but it is probably the most important criteria in determining infrastructure priorities. There are many types of risk associated with infrastructure systems including lost revenue, patient safety, cost premium for emergency repairs, and health hazards.

One of the primary objectives of a comprehensive infrastructure plan is to manage the risk. Risk cannot be eliminated but it can be managed. Infrastructure risk management often requires interim, short-term measures. Measures might include additional investigation to solve a complex problem such as an indoor air quality and electric power quality issue.

Many infrastructure plans fall short regarding the issue of risk. The competition for capital requires that all expenditures be carefully examined and prioritized. An objective infrastructure risk assessment helps in making tough decisions and provides a quantifiable means of determining what needs to be done.


An effective infrastructure plan provides the information necessary to make decisions, compete for funding, manage the risk, and strategically extend the life of a facility for the best possible long-term value. Infrastructure priorities change and need to include the flexibility to adapt. Generally infrastructure deficiencies that have an element of life safety or can result in health hazards are given the first priority. Projects are also prioritized based on the planned implementation of building projects and available funding. A less aggressive approach will spread the projects over a longer time frame. This strategy can trigger the necessity for short-term strategies to help mitigate more immediate risk that can increase the overall cost.

The advantages of maintaining an up-to-date infrastructure plan in a health care facility are numerous. A proactive approach to infrastructure will result in lower long-term cost, managed risk, and improved patient and staff satisfaction. The cost of a typical infrastructure plan can be quickly offset by savings and cost avoidance. ES

Sidebar: Keeping up by logging on

Master facility plans and infrastructure plans have long-term value if they are updated and maintained as projects are implemented and as significant changes occur. Once a document is issued, it becomes difficult to track the latest changes and updates to ensure that multiple copies of the report contain the latest information. Locating copies of the report, replacing pages, and keeping the information up-to-date becomes very difficult.

Web-based reports can simplify report access and the ability to update information. Making the drawings, summaries, and capital cost plans available online makes the information much more accessible and easier to keep up to date. Passwords and access levels can be established to protect confidential information and limit access where necessary. Web-based reports can include links to related information such as photographs, CAD drawings, and computer-generated models. Getting to the information becomes as easy as logging on to the Internet from your desktop.

In short, people are more likely to use the information when it is easy to access and they know that the information is up-to-date.