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Integrated Healthcare Facilities Maintenance Management Model: Case Studies
Integrated Healthcare Facilities Maintenance Management Model: Case Studies
www.emeraldinsight.com/0263-2772.htm
Healthcare
Integrated healthcare facilities facilities
maintenance management model: management
case studies
107
Sarel Lavy
Department of Construction Science, College of Architecture, Received July 2008
Texas A&M University, College Station, Texas, USA, and Accepted September 2008
Igal M. Shohet
Department of Structural Engineering, Ben-Gurion University of the Negev,
Beer Sheva, Israel
Abstract
Purpose Increasing demand for healthcare services world-wide creates continuous requirements to
reduce expenditures on non-core activities, such as maintenance and operations. At the same time,
owners, users, and clients of healthcare expect a high level of built-facilities performance and
minimized risks. The objective of this research is to develop an integrated facilities management (FM)
model for healthcare facilities.
Design/methodology/approach The paper presents a case study analysis of an Israeli acute care
hospital, in which the integrated healthcare facilities management model (IHFMM) was implemented,
and the findings were examined and evaluated three years later. The case studies investigated the
effectiveness of the developed model in terms of maintenance and performance management. The
robustness of the model was also examined by applying sensitivity analyses to its parameters.
Findings Both of the case studies show significant results in predicting FM-related aspects, such as
the level of performance and the required maintenance budgets. The findings reveal a high correlation
between the two phases of the case studies in terms of financial outcomes and performance
predictions.
Originality/value The core of the model is based on the strength of identified effects of certain
parameters, such as maintenance expenditure and actual service life, on the performance and
maintenance of healthcare facilities. The proposed IHFMM addresses two core topics of FM:
maintenance and performance, for strategic FM decision making.
Keywords Facilities, Health services, Cost analysis, Modelling, Israel, Resource allocation
Paper type Case study
Introduction
Increased competitiveness in the business sector puts considerable pressure on
companies to reduce expenditures on non-core activities, such as maintenance and
operations. This encourages buildings owners and users to raise their expectations
and requirements of facilities. Facility managers are thus expected to attain lower
operational costs and risks through effective and efficient design, construction,
management, and maintenance of facilities, without compromising their performance.
Over the past three decades, the field of facilities management (FM) has witnessed Facilities
significant development, mainly due to the following five global trends: Vol. 27 No. 3/4, 2009
pp. 107-119
(1) increased construction costs; q Emerald Group Publishing Limited
0263-2772
(2) greater recognition of the effects of space on productivity; DOI 10.1108/02632770910933134
F (3) increased performance requirements by users and owners;
27,3/4 (4) contemporary bureaucratic and statutory restrictions; and
(5) recognition that the performance of facilities is highly dependent on their
maintenance (Shohet, 2006).
Background
Facilities Management has traditionally been regarded in the old-fashioned sense of
cleaning, repairs and maintenance (Atkin and Brooks, 2000). A decade ago, FM
responsibilities broadened to encompass buying, selling, developing and adapting
stock to meet wants of owners regarding finance, space, location, quality and so on
(OSullivan and Powell, 1990). Recognition of the effects of space on productivity
stimulated the development of the Facilities Management discipline (Alexander, 1996;
Brown et al., 2001; Douglas, 1996; Granath and Alexander, 2006; Kweon et al., 2008;
Neely, 1998; Then, 1999). From the 1990s onward, there has been a trend toward more
open markets, and especially toward gradually increased competition, as a result of
globalization (Hamer, 1994). Now, at the beginning of the twenty-first century, it is
recognized that property is a cost-center that can contribute to the performance of an
organization, and as such, it requires effective management. As stated by the
International Facility Management Association (IFMA, 2004), FM is [a] profession
that encompasses multiple disciplines to ensure functionality of the built environment
by integrating people, place, process and technology.
Drivers of healthcare facilities management are discussed extensively in the
literature. Gallagher (1998), for instance, defines the following six issues as
encouraging successful implementation of healthcare FM: strategic planning,
customer care, market testing, benchmarking, environmental management, and staff
development. Amaratunga et al. (2002) demonstrate a model developed for assessing
the impact of organizational FM cultural processes (SPICE-FM) on a hospital facility.
The healthcare sector in many countries suffers from an under-investment in the
allocation of resources, as reflected in different financial reports (AHA, 2004; British
Ministry of Finance, 2003). This trend might adversely affect the non-core activities of
healthcare providers, and primarily facilities management aspects, such as
maintenance and operations. Ritchie (2002) posits that improving the delivery of
healthcare services, as well as the services performance and quality, can be achieved
by paying similar attention to the quality of service as is paid to financial issues. The
reforms made by the UK government in the National Health System (NHS) during the
1980s and 1990s improved efficiency by increasing the responsibilities given to the Healthcare
management level (Procter and Brown, 1997). facilities
From this review of literature the authors of this paper conclude that the
effectiveness of healthcare services will increase with the growth and development of management
the facilities management profession. This in turn will lead to a change in the position
of FM in healthcare organizations to being a more central part of the organization a
position that will help shape organizational decisions and processes. 109
The following paragraphs depict the rationale, reasoning, and functions of the major
procedures, as developed in the IHFMM. These represent five out of the 15 developed
procedures, and they were selected as the core of the model. The discussion will also
assist in understanding the case study, presented in the following sections.
where BPI is the building performance indicator, APi, j is the actual physical
performance score for system j in building i measured on a 100-point rating scale,
110 LCCi, j is life cycle costs for system j in building i, and LCCi is total life cycle costs of
the building.
This procedure acts as a physical assessment mechanism that monitors the building
and its systems and components. Nevertheless, instead of being a tool used only to
assess the physical condition of a building, it also incorporates an
engineering-economic aspect that supports the weighting of the different systems in
a building while taking their LCC into consideration. It provides the facility manager
with a novel perspective that creates a simultaneous link between physical
performance and the economic aspects of building systems. As an
economic-performance indicator, it is used in a later stage of the analysis to assess
the efficiency with which the actual performance is achieved.
Other qualitative approaches may also be considered for assessing the physical
condition of a building; however, the authors believe that these approaches are
subjective to the evaluator, and may not completely reflect the actual performance and
functionality of the building and its systems. As a result, weighting the building
systems by their contribution to the total life cycle costs of the entire building was
selected as the approach used for the purpose of this study.
Facility coefficient
The facility coefficient procedure computes the adjusting coefficient for the annual
maintenance expenditure (AME). This coefficient is affected by the type of
environment in which the facility is located (whether marine or in-land
environment), its occupancy (low, standard, or high), the actual age of the buildings
in the facility, and the individual configuration of the buildings in terms of the amount,
type, and quality of the components (Lavy and Shohet, 2007a). The coefficient
expresses the maintenance resources required for implementing a policy of preventive
and breakdown maintenance. Each building is then compared with a normative
hospital building, with the characteristics of location in an in-land environment (more
than 1,000 meters off the Mediterranean coastline), facing a standard level of
occupancy (a yearly average of ten occupied patient beds per 1,000 m2 of floor area),
and high quality of components to be installed. A facility coefficient of 1.15, for
example, represents a requirement to invest 15 percent more in maintenance activities
than in a standard hospital building, under standard service conditions.
In this research, six simulations were conducted to examine the total maintenance
requirements during the designed lifespan of a hospital building under different
service conditions (Lavy and Shohet, 2007a). The conclusions drawn from these
simulations reveal that the AME in extreme conditions may vary from 9.0 percent
lower (in-land environment and low level of occupancy) to 18.6 percent higher (marine
environment and high level of occupancy) than standard conditions. This observation
is significant, since it means that the AME in built facilities depends significantly on
factors such as the type of environment in which the facility is located, and even more,
it depends on the level of occupancy in the facility and on its actual age. Consequently,
the implementation of this coefficient elucidates an uneven allocation of resources in Healthcare
healthcare facilities; it also explains that the particular conditions of each facility facilities
should be taken into account.
management
Annual maintenance expenditure (AME) and normalized annual maintenance
Expenditure (NAME)
Annual maintenance expenditure (AME), measured in $US per square meter, expresses
111
the amount of resources spent on maintenance and replacement (also known as capital
renewal) activities during a fiscal year, and combines expenditures on in-house
personnel, outsourcing contractors, and materials and spare parts (Shohet et al., 2003).
Any activity intended to prevent a failure or deterioration of building components, to
repair a component that failed, or to replace a component as it reached the end of its
service life is included in the AME. This indicator may be used to normalize the
expenditures in a facility from one year to another, as well as to compare maintenance
expenditures between different facilities.
The normalized annual maintenance expenditure (NAME) is defined as the AME
divided by the facility coefficient. This eliminates the effects of building age, level of
occupancy, category of environment, and configuration of building components by
normalizing the annual maintenance expenditure into a value that can be compared to
other facilities of different ages and under different service conditions. This parameter
can be combined with the BPI as an indicator for the building performance to cost ratio.
Projected performance
Similar to the BPI, projected performance computes performance scores of the building,
systems, and components on a 100-point scale. This procedure, however, aims to
project the future level of performance for the different systems in a building (Lavy and
Shohet, 2007b). In order to predict the performance of each component, it is assumed
that its deterioration pattern is either linear or non-linear (Moubray, 1997). Then, each
building system is weighted according to its share in the LCC of the entire building.
The projection of a buildings performance aims at forecasting the future level of its
functional condition based on actual monitoring of its performance. In this research,
patterns of performance projection were developed for 51 main building components.
Based on this, future performance can be projected for each system in the building, for
the building as a whole, and for the entire facility that is composed of several buildings.
This study proposes the use of different patterns of deterioration not only to predict the
performance of a single element or system in a building, but to project the performance
score for the entire building and even of the entire facility, using LCC as the weighting
principle for the buildings various systems. Moreover, it allows FM decision-makers to
break each building down into its individual systems, and to analyze it at a great level
of detail, down to its components. In addition, the model is flexible and able to
accommodate any change in the patterns of deterioration. This means that if future
research reveals that the deterioration pattern of a particular component is exponential,
changes in the databases can be effected with no significant effort.
Likewise, the projected performance mechanism does not consider renovation or
capital improvement projects that may be conducted in a building. Since these types of
projects depend on the mission of the building, as well as on available resources, it is
F very difficult to plan for and incorporate them into the prediction model. Thus, the
27,3/4 authors suggest that further research is required in this area.
113
Plate 1.
Aerial view of the hospital
used as case study
Figure 1.
BPI vs NAME of the case
study hospital
Building # Actual performance 2001 Projected performance 2004 Actual performance 2004
Conclusions
Existing methods for facilities management decision-making are limited, particularly
at the strategic level of facilities management. This research focused on identifying
principal parameters that affect the performance and maintenance of facilities
throughout their service life. An integrated healthcare facilities management model
has been developed, which proposes simultaneous analysis of the complexities
involved in the field, such as resource allocation and setting of maintenance policy for a
given level of performance, or improving efficiency with which the implementation of
maintenance activities are carried out. These complexities are dealt with by almost all
facility managers of public as well as private facilities; nevertheless, this point is even
more crucial and significant in healthcare facilities that operate 24 hours a day, seven
days a week, provide care and treatment services, and support critical infrastructures
of healthcare such as medical gas and power for operating theatres.
The model developed in the research includes 15 procedures, out of which five core
procedures were discussed in the frame of this paper: building performance indicator,
facility coefficient, annual maintenance expenditure, projected performance, and
maintenance efficiency indicator. The implementation of the methodology was
illustrated by two case studies that confirmed the viability of the model. Both of these
case studies show high correlations and significant results, by predicting different
FM-related aspects, such as the level of performance and the required maintenance
budgets.
The models robustness was examined using sensitivity analyses. Two principal
factors were considered: inaccuracies in the performance scores, and sensitivity to the
hypothesized deterioration patterns of building components. Robustness of the
predictions of the model is achieved primarily due to the central limit theorem.
The present research enables an analytical hierarchical process for facilities
maintenance strategic and operational decision making by simultaneous analysis of
facilities maintenance core parameters. The core procedures are illustrated in this
research with the building performance indicator, facility coefficient for the adjustment
of the maintenance resources to prevailing building environment and occupancy, and
maintenance efficiency, as expressed by the ratio between expenditure on maintenance
and performance.
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