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Improving commissioning of healthcare facilities through integrated systems testing

The role and complexity of technology in health is increasing to drive efficiency and better health outcomes. As healthcare, technology and buildings are becoming more and more integrated and complex, the risks associated with commissioning hospitals are increasing.

Commissioning is when a project starts to become a health service as the users begin to take ownership of the hospital. Failure in commissioning can significantly impact the hospital’s users, including patients, clinicians, nursing staff and hospital engineers. In an environment where patient safety is essential, a poorly commissioned hospital puts this at risk.

Even if a project is in all other aspects hugely successful, if commissioning goes awry, the long-term repercussions can be significant. The risks associated with commissioning need to be acknowledged and managed. How can integrated commissioning help manage this risk both now and into the future?

The importance of integrated systems testing to successful commissioning

The terms commissioning, total building commissioning and integrated systems testing (IST) are widely used but are frequently undervalued and often given a lesser priority in the rush to meet the project practical completion deadlines. However, these processes are beneficial and essential to the seamless handover of a healthcare facility.

IST is one subset of these processes, and when delivered comprehensively can heavily de-risk the completion process by addressing the potential disconnection between designers and trade contractors who may design, test and commission their respective systems in silos. When a disconnect occurs, the overall facility operation and operation in normal failure modes may not be thoroughly proven.

An IST process provides a holistic approach and methodology through a regimented series of testing that addresses a predefined series of operational and failure scenarios. Through this process, the correct operation of all systems can be demonstrated individually and collectively to provide a predicable operational outcome.

While IST is a widely acceptable deliverable concept at the practical completion stage of a healthcare project, criteria for a pass or fail is rarely defined comprehensively. Third party statements are also commonly relied on for final assurances. Also, as operation and interfaces are not physically tangible assets that can be sighted and accounted for easily, there is a risk that acceptance of a completed installation may be provided prematurely.

Carrying out IST in an unstructured, ad-hoc manner can lead to unplanned downtime, resulting in reputational, programme, material and financial loss. It can also have adverse impacts on occupant and patient safety and wellbeing from incorrect operation of life safety, electrical, electro-medical, security and infection control systems.

So how can we improve the way we use IST process to ensure success?

Adopting a standardised, quantitative approach

With inconsistency in IST responsibility and process, as well as little guidance on testing, there is a tendency to rely on previous experiences and a qualitative approach, as well as the use of bespoke solutions. Also due to inconsistencies and misconceptions around what is actually required in the IST process variations in fees and costs occur between individual parties.

The solution to this is a more quantitative approach using comprehensive guidance, frameworks, and worksheets. Examples include the globally recognised American Society of Heating, Refrigeration and Air-Conditioning Engineers (ASHRAE) tools, National Environmental Balancing Bureau (NEBB) certification, Bureau of Conformity Assessment (BCA-US) and other Failure Modes and Effects Analysis (FMEA) tools.

A quantitative approach uses traditional risk assessment methodologies to normalise predicted outcomes so the effect can be measured with and without the hierarchy of controls being provided. This standardised platform means assurances can be given that the right scenarios have been addressed, the right mitigations have been designed and finally the post-construction forecasted operation can be tested and recorded.

Staying on track with project completion and budget by starting early

Crucial to the success of IST scenario testing is starting early so the quantitative approach can be developed, agreed, and forecast in construction programming. IST scenario testing can then be scheduled, tracked, and flagged if progress and milestones are not being achieved.

Skipping or compressing these steps inevitably moves the process into the more uncertain qualitative approach and risks compromising the outcome or pushes IST past practical completion and into the operational phase of the health facility.

Completing IST post-occupancy creates a number of complexities including after-hours testing, increased project management requirements, system redundancies, the need for scheduled outages and additional costs, as project timelines are extended. By starting early, projects are more likely to be finished on time without the need to revisit IST.

Technology is the critical starting point

With the rapid growth in data capture needs in hospitals, an increasing number of devices are now using local area networks (LAN) connected protocols to communicate between systems.

Increased usage of the IT networks by these devices means that earlier completion, handover and commissioning of infrastructure and spaces that support this IT network is now required. However, the IT needs of healthcare facilities are further complicated by using single or unified networks to improve efficiencies and reduce redundancies.

This single network topology has resulted in a shift of critical path construction activities towards the information and communication technology (ICT) systems. With careful planning, these systems need to be brought online and tested early in the process so sub-systems can then be properly commissioned. Once this has occurred, the meaningful IST process can commence.

Utilising independent commissioning agents to manage and track process

On top of the financial drivers for best practice IST, the various green building tools have acknowledged that the inclusion of an independent commissioning agent (ICA or CA) is critical to the success of completed healthcare facilities to meet their aspirational design targets.

It can be difficult to determine ownership of the IST process. However, there is an opportunity for this same ICA to also be the resource to support the IST process due to their intimate knowledge of the general commissioning process.

Embedding or hiring a knowledgeable ICA provides value through:

  • Being a third-party resource that provides independence and unbiased findings
  • Seeing the bigger picture and not needing to defend the design or installation without seeing the bigger picture
  • Providing testing, commissioning, and maintenance suggestions during the design phase
  • Reviewing testing plans, equipment selections and interfaces between systems to minimise gaps between design and construction parties
  • Removing the subjective or qualitative approach to commissioning and IST

Reducing complexity in failure scenarios both now and into the future

There is a high level of operational complexity introduced by the need for stakeholders and design teams to account for all failure scenarios and for these to have a fully automated response. This catch-all approach means many complex scenarios with a low probability of occurring compound into more complex programming, logic analysis and sophisticated interdependencies.

This might drive counterintuitive routines during operation, making the facility hard to operate, less likely to be understood and less trusted by facility management teams in times of operational crisis.

To reduce the impact of this, simplifying the design and operation of these systems is crucial. This can be done through prioritising responses. By addressing only realistic, high probability, real world failure events with automated responses, and addressing other scenarios with manual intervention, this substantially reduces complexity, and means that high re-programming costs are avoided to change system functionality when it is finally discovered it is too complicated to manage.

These ad hoc events can be articulated in operating and maintenance procedures that can be risk assessed and carried out by the team on the ground when/if they ever occur.

Utilising IST process to improve commissioning overall

A robust approach to integrated commissioning can help to reduce risk and cost of healthcare infrastructure projects. IST is not a new concept and even in a volatile construction industry and an increasingly technologically advanced healthcare sector, a well-designed, logical, managed and properly implemented quantitative IST process will help hit the traditional project delivery metrics of time, cost and quality.

The success of the IST process can be improved by:

  • Using a more quantitative approach rather than relying on qualitative methods
  • Staying on track by starting early to avoid delays to commissioning
  • Acknowledging that IT networks are a critical starting point to commission before IST can commence
  • Using readily available independent commissioning agents to manage and track process
  • Simplifying the design of the facility failure modes and interfaces to reduce operational complexity

We know that the increasing cost of health is unsustainable. As our populations grow and age, the pressure on our health systems will continue to mount.

We believe that to help address the pending health affordability gap, the shape of our health system and hospitals must change. A far more integrated approach to planning, delivery and operation across health services, buildings and technology will be needed to support this.

Technology will inevitably have an increasing role to play. With an even greater level of integration and dependency on technology ahead, we believe new approaches to commissioning are needed. By utilising quantitative approaches, planning early and simplifying the process, new processes and standards for commissioning hospitals can be realised.


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About the Author

Susie Pearn has over 20 years’ extensive experience working with private and government bodies on highly complex social infrastructure projects. She has played lead management roles in the planning and delivery of numerous social infrastructure programmes and projects, including ones over a USD billion dollars in value.

Susie also has an advisory skill set and an asset management background, bringing a diverse perspective. She has a particular interest in the convergence of services, infrastructure and technology and how this can achieve more productive and sustainable outcomes.

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