See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/318683641

Healthcare facilities maintenance management: a literature review

Article  in  Journal of Facilities Management · July 2017

DOI: 10.1108/JFM-10-2016-0040

CITATIONS READS
60 18,786

3 authors:

Zahra Yousefli Fuzhan Nasiri

Concordia University Montreal Concordia University Montreal
9 PUBLICATIONS   94 CITATIONS    119 PUBLICATIONS   1,732 CITATIONS   

SEE PROFILE SEE PROFILE

Osama Moselhi
Concordia University Montreal
385 PUBLICATIONS   6,678 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Operational Clash Detection & Aviodance View project

Self Activated Floating Barriers(SAFB) View project

All content following this page was uploaded by Fuzhan Nasiri on 26 April 2020.

The user has requested enhancement of the downloaded file.

 Healthcare Facilities Maintenance Management: A Literature Review

Abstract

Purpose –The complexity and criticality of healthcare services highlight the importance of
maintenance management function in healthcare facilities. The purpose of this paper is to review
the literature on maintenance management of healthcare facilities and hospital buildings to
provide an organized literature review and identify gaps from the perspective of research and
practice.

Design/methodology/approach – The paper categorizes the literature and adopts a review

hierarchy according to maintenance management functions in hospital buildings. It explores the
impact of those functions on the performance of maintenance activities in hospitals. Furthermore,
it examines the role of Information Technology (IT) and Automated Decision Support Systems
(DSS) in facilitating hospitals maintenance management functions and performance.

Practical implications – Literature on maintenance management in healthcare facilities and

hospital buildings has so far been very limited. Recently published literature focusing on health
care facilities management and its maintenance management functions is classified into various
areas and sub-areas. The paper highlights gaps in the literature and suggests avenues for future
research and improvements.

Originality/value – The paper contains a comprehensive listing of publications and their

classifications according to various attributes. It will be useful for researchers, maintenance
managers, practitioners, stakeholders concerned with facility management of hospital buildings.

Keywords: Hospitals, Maintenance Management, Facility Management, Performance

Measurement, Information Technology

Paper type: Literature review

1
1-Introduction
The demand for healthcare services and facilities are ever increasing in the 21st century due to
population growth, increased life expectancies, and elevated standards of life (Hosking and
Jarvis, 2003). The growing urbanization has also created the need for more complex hospital
buildings. Nowadays, the urban hospitals need to provide a diverse set of health care services to
a vast number of patients and visitors in a more condensed, congested and concentrated space.
This has emphasized the importance of facility management (FM) in the healthcare sector
(CHFM, 2016). In this regard, maintenance management is one of the most challenging and
costly elements in hospitals (Chotipanich, 2004; Shohet, 2006). It supports functioning and
continuity of care facilities and services of hospitals as critical as emergency and lifesaving care
facilities (Shohet et al., 2003). Maintenance might also affect many non-core activities of
hospitals such as food storage and supply, cleaning, and security of buildings (CHFM, 2016).

National Health Service (NHS) in the UK has advocated the integration of noncore
healthcare services under the responsibilities of FM (Rees, 1997; Rees, 1998). They have
identified several issues necessary to address to implement an integrated FM in NHS that
includes maintenance strategic planning, maintenance benchmarking, customer care, market
testing, environment and staff management (Gallagher, 1998).

A number of studies have been reported in the literature (with mentioning of hospitals
and healthcare facilities) on maintenance management issues (Garg and Deshmukh, 2006),
facility management implications (Ventovuoriet al., 2007), KPIs for facility performance
measurement (Lavy et al., 2010), and maintenance performance metrics (Kumar et al., 2013).

Shohet and Lavy (2004a) reviewed published literature in healthcare FM domain. On that
basis, they proposed five subcomponents for healthcare facility management including
maintenance management, performance management, risk management, supply services
management and development.

Garg and Deshmukh (2006) reviewed the literature for maintenance management and
identified several research gaps. In particular, they pointed to the need for customization and
implementation of maintenance optimization models in the form of operational decision support

2
systems, measurement of maintenance performance by considering its links to decisions outside
maintenance unit, and integration of IT in maintenance management, just to name a few.
Lavy et al. (2010) discussed current measuring metrics and key performance indicators
(KPIs) for facility management practices. They classified these indicators into “cost-related” and
“non-cost related,” or “functional” and “physical” categories. Kumar et al. (2013) identified
techniques to formulate performance indicators for maintenance performance measurement
(MPM). Their research illustrated the value and applicability of MPM frameworks for the
organization.
Table 1 provides a summary of the earlier literature review papers that are related to
facilities and maintenance management in the context of hospitals and health care system. These
reviews are either capturing the intersection of facility management practice, and health services
that are dealing with maintenance management in buildings in general. To the best of the
authors’ knowledge, no literature review has been conducted with a focus on maintenance
management approaches and issues pertinent to hospitals. In this sense, this paper aims at
identifying and organizing available literature in the field of maintenance management for
healthcare facilities.
This study highlights the gaps in the literature and suggests directions for future research.
It is organized into five sections. After the introduction, the existing literature on maintenance
management in hospitals is reviewed and classified into a hierarchy that follows a typical
maintenance management process in hospitals. It gathers different models and methodologies
from scattered references and identifies gaps related to various levels of this hierarchy. Many of
the reviewed articles are dealing with the use of information technologies (IT) and decision
support systems (DSS) in implementing, facilitating and improving the maintenance
management in hospitals. As IT and DSS deal with maintenance issues at all levels, we decided
to create a separate section to highlight the specific role and impact of information technology
and decision support systems in maintenance management with respect to the peculiarity of
issues and complexities in hospitals. This will be followed by a summary and a conclusion,
where we recall and enlist the existing gaps in the literature and recommend avenues for future
research.

3
2- Proposed Hierarchy
We identified the available literature in the field of maintenance management for healthcare
facilities, using a range of keywords as reported in Table 2. We searched in the articles’ titles and
keywords. These articles were distributed among several journals as presented in Table 3. The
type and frequency of the subject areas of these articles, as shown in Table 4, directed us to
organize the literature review into a hierarchy (as depicted in Figure 1) based on a typical
maintenance management process in hospitals. We follow a hierarchy of maintenance
management activities from strategic level to tactical and operational ones, covering the topics
that are established or emerging in the literature. As such, we classified the tactical issues under
the umbrella of costing, sourcing, and contract management. The operational aspects are also
organized into resource allocation and risk management. It should be mentioned that in our
review, we have defined “resource allocation” generic enough to account for time, labor,
physical assets, equipment, spare arts, and other operational requirements. This process will
conclude at the overarching component of “maintenance performance” where the whole process
is monitored and evaluated for performance improvements.

2.1. Maintenance strategies

Maintenance is defined as “the combination of all technical and administrative actions,
including supervision actions, intended to retain an item in or restore it to, a state in which it can
perform a required function” (BS 3811:1993).

Shohet and Lavy (2004) have a similar definition “ensuring the continuous, cost-effective fitness
for the use of buildings at a specified performance level.” In this sense, to achieve a cost efficient
and operationally effective maintenance system, long–term strategic planning for various
functions of maintenance is necessary.

In doing so, prioritization/categorization of building components based on recorded data

on failure incidents and root causes of them is the first step towards maintenance (strategic)
planning decisions (Sullivan et al., 2004). Building maintenance strategies are divided into
unplanned (corrective) or planned (preventive), and predictive maintenance approaches (Rani et
al., 2015). Corrective maintenance (CM) occurs when a component is going out of function and

4
needs intervention in the form of repair or replacement (Higgins et al., 2002). On the other hand,
Preventive maintenance (PM) includes planning of periodical repairs or replacements at defined
time intervals (Gross, 2002). Predictive (proactive) maintenance monitors the symptoms and
likelihood of a failure to make-in-advance maintenance interventions based on these predictive
measures (Ben-Daya, 2009). The main factors that dictate the choice of a maintenance strategy
are the maintenance budget and criticality (and complexity) of the failure (Horner et al., 1997).

The choice of maintenance strategy in hospitals, as complex buildings (with a lot of

mechanical and electronic components, systems, and equipment), is significantly impacted when
the maintenance budget is limited. This has been particularly reported as one of the main
maintenance related issues in public hospitals (Loosemore and Hsin, 2001). Kutucuoglu et al.
(2001) highlighted customer satisfaction as another dimension that forms the maintenance
strategies in hospitals. They indicated that the performance of maintenance function is impacting
and shaping the clients’ satisfaction and (public) perception about a hospital. Rani et al. (2015)
conducted a customer satisfaction survey in some healthcare facilities. Their findings show that
there is a direct relationship between customer satisfactions and maintenance strategies. They
indicated that preventive maintenance should be adopted as a preferred maintenance strategy in
hospitals. They highlighted the fact that the maintenance activities with a periodical schedule are
more appealing to users of hospitals including the patients, visitors, and the staff. Due to its
unpredicted nature, in reactive (corrective) maintenance, the personnel might not be familiar with
the root cause of the breakdown, which could contribute to delays, reworks, disruption of
services, and an increased cost of maintenance. Diez and Lennerts (2009) developed a cost
estimation model directing the cost/budget allocation for FM services related to operation units
of four hospitals in Germany. In particular, they have highlighted and quatified the relationship
between the cost of FM services and their observed performance.

In summary, according to the above-reviewed literature, very limited research has been
reported on the identification of appropriate maintenance strategies (and linking them
maintenance activities) in hospital buildings. This is considered a major research gap, as the
choice of maintenance strategy, shapes the tactical and operational decisions in healthcare
maintenance management (that will be discussed in the following sections).

5
2.2. Maintenance cost, sourcing, and contract management
Several factors affect maintenance expenditures. We have identified few studies in the literature
that review maintenance costing in buildings, mostly without a focus on hospitals.

These studies have shown that the biggest amount of expenditures that occur in the
service life of buildings are associated with their operational phase, which includes maintenance
activities (Flanagan et al., 1989; Liu et al., 1994; Kirk and Dell'isola, 1995; Johnson et al., 1999).
In particular, Umeh (1994) developed a model consisting of the operation and maintenance cost
of hospitals. He identified the source of financing and measured its impact on rising cost of
maintenance in hospitals. Stolavs Hospital in Norway was examined to determine factors
affecting its operating cost (Nesje, 2002). It is advocated that the rate of occupancy per bed, age,
scale, and morphology of hospitals are the factors with greater impact on maintenance costs.

A number of studies also highlighted benchmarking as a tool to test and measure the
operational and maintenance costs in healthcare facilities (Sliteen and Catarina, 2010; Sliteen et
al., 2011). They categorized costs of a healthcare facility into investment costs, operation and
maintenance costs, and disposal costs. They gathered data on the number of patients and beds,
operation and maintenance activities, utilization rate of water, gas, and other utilities. The
authors demonstrated the economy of scale on the cost of maintenance, O&M staff cost, and cost
of utilities. In doing so, they have used cost per bed ratio instead of using cost per square meter
of floor area. They showed that the latter has a strong correlation with the expenses mentioned
above.

Boussabaine et al. (2012) presented the relationship between bed usage and operational
costs in hospitals in France. They have advocated that the gross floor area (GFA) occupied per
bed is the best indicator to forecast the operational and maintenance costs in the hospitals. Assaf
et al. (2011) identified the factors that affect the cost of maintenance in hospital facilities. They
have listed 33 factors that influence maintenance costs in hospitals. These factors were
categorized into seven subgroups with separate considerations for public and private hospitals.
These subgroups consist of legal requirements, design phase requirements, construction phase
requirements, maintenance requirements, projected budget for maintenance activities, expected
maintenance performance, and the norms and benchmarks in the maintenance industry. Al-
Zubaidi and Christer (1997) proposed a model that deals with the personnel recruitment and

6
allocation for maintenance activities in hospital buildings. They captured the relationship
between recruited/allocated labors and maintenance demand.

In addition, the literature also points to the fact that the O&M staffing and its sourcing
have a significant influence on maintenance cost (Sliteen and Catarina, 2010). Therefore, the
sourcing of maintenance services in hospitals (outsourced vs. in-house maintenance) and the
structure and type of maintenance contracts are of particular importance. Ikediashi and Ekanem
(2015) have surveyed 74 hospitals to investigate their experience with outsourcing of FM tasks.
Outsourcing and insourcing of maintenance activities have their advantages and issues.
Outsourcing relies on the external expertise and thus the internal skills and experience will be
ignored (and lost in the long term). Also, some of the insource management and control
authorities and responsibilities will be compromised via outsourcing contract and will be
delegated to the external expertise. On the other hand, outsourcing has some merits including the
cost efficiency gains, access to external state-of-the-art expertise and resources, and providing
the internal team with a reduced workload to focus more on monitoring and ensuring the quality
of outsourced maintenance services (Shohet et al., 2003). A survey of more than 700 hospitals
illustrated the fact that almost half of the annual maintenance expenditures were spent on
maintenance staff and over a third of that were devoted to external contractors (Shohet et al.,
2003). This highlights the most common arrangement of outsourced and in-house staffing in
hospitals.

Franceschini et al. (2003) proposed a model for the outsourcing decision-making linking
strategic decisions, economic factors, and human resources. This model analyzed internal and
external benchmarks as relate to determining outsourcing work requirements, selection of service
provider, and contract management. Powell (2002) suggested a model to manage the outsourcing
of services in FM for a general hospital. He asserted that all of the FM practices in hospitals
could be outsourced. Shohet (2003a) advocated that the success of a maintenance outsourcing
practice depends on the level of hospital occupancy. In hospitals with a high rate of occupancy,
facilities are subject to a higher rate of deterioration requiring available in-house work sources to
do corrective maintenance. Otherwise, with lower rates of occupancy, outsourcing could create
more cost efficiency gains by delegating non-core FM activities to the external workforce
(Shohet, 2003a). Mosadeghrad et al. (2011) mentioned that there is a positive correlation

7
between (in-house) employees’ satisfaction and hospitals’ maintenance commitment. Ciarapica
et al. (2008) showed that for small hospitals employing outsourced personal is more costly than
internal ones while for large hospitals outsourcing services are more cost efficient as the risks
arising from complexities of large hospitals are outsourced. They suggested that there are
research gaps on how the selection of the contractors needs to be carried out and how the work
should be divided between in-house and outsourced personnel when both groups are on site.
Ali and Wan Mohamad (2009) have discussed the contractor’s service performance as a
major issue in maintenance outsourcing contracts. They have indicated that the performance
monitoring and control of external contractors have not yet been formalized in many hospitals.
Straub and Van Mossel (2007) suggested a performance-based contract mechanism used to select
an outsourcing contractor (among alternative contractors). To be selected, a contractor must
propose their choice of maintenance strategies considering the future scenarios of the hospital in
terms of services and requirements as well as the user satisfaction issues related to maintenance
activities. In addition, a recent study indicated that performance-based maintenance contracts are
approximately 20% less costly in comparison with perspective-based contracts and
recommended this type of contract as a basis for performance assessment of maintenance
activities carried out by external contractors (Straub A. , 2009).
Alzaben et al. (2014) proposed a Current Reality Tree (CRT) to identify the main issues
affecting and causing delays in maintenance works in hospitals. They proposed “lack of skills,”
“insufficient communications,” “low team motivation,” “limited budget” and “low standard of
contract work” as the major causes of the deferment in maintenance practices in hospital
buildings. Shohet and Nobili (2016) mentioned that there is a gap between the financial
resources available for maintenance in hospitals and the maintenance management expectations
and requirements.

In summary, the literature points to several factors that affect the cost of maintenance in
hospital buildings. Several studies have tried to capture the relationship between cost,
composition of in-house and outsourced personnel, and the maintenance contract. However,
further research would be needed to develop indicators and benchmarks to assist hospitals in
establishing the cost of maintenance and in shaping the maintenance (sourcing) contracts
accordingly.

8
2.3. Maintenance resource allocation
In recent years, facility managers are under increasing pressure to prioritize their ever declining
resources for maintenance and replacements (Lavy et al., 2014a). Some of the commonly
reported consequences of failing to establish such a prioritization might include unscheduled
required maintenance, additional expenses, and reworks in repair and replacement activities, and
an increasing stock of aged components.

In the sense of the current business environment, enterprise resource planning (ERP) has
been recommended as a management system to integrate flows of information, materials, and
monetary transactions (Lee and Kwak, 2011). In health care sector, ERP systems are extended to
integrate with customer relationship management (CRM), supply chain management (SCM), and
clinical decision support systems (CDSS) (Lee and Kwak, 2011). Incorporating maintenance
activities in ERP systems can also enable facility mangers to monitor the functioning of the
components of a hospital in real time (Rajagopal, P., 2002).

ERP systems were originally implemented in manufacturing processes. The research

shows that there are key differences between requirements in manufacturing and healthcare
facilities when it comes to ERP (Grimson, 2001; Pedersen and Larsen, 2001). As such, ERP
needs to be customized for healthcare applications to incorporate attributes of each peculiar
hospital such as financing, manpower recruitment and circulation, space and equipment
capacities, revenue management, and the patients’ admission and care units (Lee and Kwak,
2011). In doing so, Shohet and Nobil (2016) developed an ERP model for maintenance of
clinical facilities in a public hospital by integrating eight key performance indicators (KPIs).
These KPIs are expressed as age coefficient for facilities (ACy), density coefficient for patients
in the clinic (DCy), building performance indicator for operational targets (BPI), annual
maintenance expenditure (AME), normalized annual maintenance expenditure (NAME),
maintenance cost efficiency indicator (MEI), maintenance sources ratio (MSR), and maintenance
management span of control (MSC). MSR represents the percentage of outsourced maintenance
resources from the total labor resources allocated for maintenance of the facility. MSC is the
indicator which shows the effectiveness of maintenance division to achieve coherence among
different parts of the organization which is represented by the number (ratio) of employees who
are directly subordinate to the maintenance manager (Mintzberg, 1981). Through a case study,

9
they have presented a number of cost saving opportunities resulted from adopting the proposed
model.
Lennerts et al., (2005) suggested an approach to cut down the expenditures and increase
the efficiency of healthcare facilities through the analysis of FM processes. They aimed at
prioritizing the FM processes in terms of their impact on core activities of hospitals. The FM
activities with least impact will be given the highest priority for cost reduction. In addition to,
Sharma et al. (2007) applied “lean” principles to identify and eliminate non-value added
activities in facilities management of a hospital in Germany. They used simulation to illustrate
and verify the impact of suggested changes on workflow process. To identify an optimal
allocation of resources (such as minimizing the number of workers in facility management team)
a number of “what if” scenarios were analyzed through the means of simulation. By
implementing “lean” principles, a less number of reworks and rejections were expected with 30
to 50 percent decrease in activity completion times.
In summary, our literature review revealed that implementation of ERP systems is
advocated for efficient allocation of resources in hospitals’ maintenance management. However,
there is still limited research on the customization of ERP systems for health care applications.
The research in this area is still very case-specific and needs industry-wide benchmarks and
KPIs.

2.4. Maintenance risk management

Risk management has long been recognized as one of the high priorities for hospitals
(O'Donovan, 1997). One of the common duties of facilities managers of hospitals is to identify
and analyze the risks (internal or external) that could threaten the functioning, security and safety
of the hospital facilities. In this sense, we have two categories of risks, the ones that could impact
the functioning of maintenance management units in hospitals, and the ones that could originate
from maintenance activities and affect other functions of hospitals.
A typical risk management process consists of risk identification, risk assessment and
risk prioritization (Waterman, 1995). In the risk assessment, the focus is on evaluating the
criticality of risks by incorporating their likelihood and impact. In the risk prioritization, the aim
is to ensure that the critical risks are addressed first and the others are carried out based on the
order of their criticality. Decision trees, sensitivity analysis, scenario analysis, simulation, and

10
multi-attribute utility theory have been used to analyze the likelihood, consequence, and
criticality of risk (Okoroh et al., 2002).
Stower (1998) discussed the hospital risks from clinical, service quality and financial
dimensions. They recommended a management plan for risks related to security, fire, inspection
incidents, COSHH (control of substances that are hazardous to health), complaints, protective
clothing, waste, workplace incidents, equipment, IT system, and aggression and violence. A risk
strategy was outlined to ensure that all of these items were considered in risk management
through identifying risks, quantifying their likelihood and impact, identifying options to mitigate
these risks, implementing the above-chosen options, and assessing the time period needed to
execute them.
Waterman (1995) organized a list of health and safety hazards in hospitals, including
hazardous substances, manual handling of them, security, violence and aggression, fire
protection, food hygiene, infection, and exposure to clinical waste. He discussed three possible
levels of the risk. The major risks which have serious outcome and must be mitigated, small risks
that should be reduced, and the tolerable ones under “no further action is required” label.
NHS hospitals in the UK face a variety of risks and uncertainty on the part of service
contractors and purchases (Okoroh et al., 2002). This includes equipment and spare parts needed
for in-house maintenance as well as the outsourced maintenance contracts. Okoroh et al. (2002)
noted that to improve service quality and avoiding clinical failures, NHS has to conduct a
comprehensive review about risks and uncertainties faced by hospitals including the ones that
facility managers of hospitals should identify and analyze. Alexander (1992) has suggested an
approach to risk management in FM operations. His model includes four stages: risk
identification, risk analysis, risk control, and financing of risk consequences and loss. Wagstaff
(1996) advocates that risk management activities in hospitals should be prioritized based on the
consequences of identified risks on cost, service quality and quantity.
Okoroh et al. (2002) developed a risk classification framework and identified the major
risk factors associated with facilities management in NHS hospitals. These risk factors are
customer care risks, business transfer risks, legal risks, facility transmitted risks (FTD), corporate
risks, commercial risks, and financial and economic risks where most of these risks cannot be
controlled by facility management unit.

11
 Lavy and Shohet (2010) considered 5 levels of risks of highly critical; critical; marginal;
low; negligible for the 10 typical building components including structure, exterior envelope,
interior finishes, electricity, sanitary systems, elevators, fire protection, communication and low
voltage, medical gases using data collected from a series of surveys conducted between 2001 and
2004 at a number of hospital buildings in Israel.
De Silva et al. (2012) identified ten risk factors of building maintainability and their
impact on maintenance costs. They studied these factors in a case study high rise building. The
results illustrate the fact that accounting for risks (and minimizing it) in maintenance decisions
will reduce the cost of maintenance.
Ikediashi and Ogunlana (2015) considered 35 risk factors related to the outsourcing of
FM services in Nigeria’s public hospitals. At the end, 24 of these factors were considered as
“critical”. They identified the top five critical factors as inexperience and lack of requisite skills;
the possibility of fraud by the vendor; financial failure of chosen vendor; vendor opportunism;
and fall in the morale of employees. As a result, they further categorized the above-identified
risks into five distinct groups of client risks, contract risks, vendor risks, political risks and
general risks.
Leung et al.(2013) identified the main components of FM in residential care and attention
(C&A) homes and investigated the risks related to these components. In this context, they
defined FM as the coordination of physical environment for the elderly in C&A home to live in a
non-risky environment. They categorized FM into three main aspects; architectural, building
services and supporting facilities component. The common risks that could occur in C&A home
include falling, collision, scalding, infection, getting lost, behavioral disorder, fire, and security.
In such an environment, the main FM responsibilities will include space planning, lighting,
fixtures& finishes, ventilations, noise reduction, thermal comfort, signage, cleanliness, safety and
security, and leisure and catering. They developed an operational model for FM to address the
risks mentioned above and to support the health and well-being of the elderly in C&A homes.
In summary, there is still very limited (mostly generic) research on identifying,
evaluating and managing facility risks in hospital buildings. The literature is even more limited
in case of analysis and management of risks associated with maintenance function in hospitals.
In today’s complex hospital buildings, we should not only consider the risks associated with
extreme events and their consequences on maintenance functions but also shall incorporate risks

12
that could arise from maintenance activities jeopardizing the continuity and quality of care
services in hospitals ( Lavy and Shohet, 2010; Roper and Payant, 2014).

2.5. Maintenance performance measurement

Maintenance performance measurement (MPM) is defined as the process of measuring the value
created by maintenance expenditures and investments (Parida and Kumar, 2006). Menge and
Mingue (2011) compared different performance measurement models in FM. These models
include Balanced Scorecard (BSC), Business Excellence Model (BEM), Key Performance
Indicators (KPIs), and Capability Maturity Model (CMM). Among them, KPIs could be defined
for activities at the operational level with a focus on maintenance to compare its targets and
actual outcomes (Chan and Chan, 2004).

May and Pinder (2008) provided a methodology to measure the relationship between the
performance of soft FM services and well-being of patients at NHS facilities. They did not,
however, consider the impact of building maintenance, which was categorized as “hard” FM.
This was considered in a follow-up study in which the perception of maintenance teams about
their performance and its impact on patients’ satisfaction was investigated (May & Clark, 2009).

In recent years, research is emerging in adopting KPIs approach for FM in hospitals.

Pullen et al. (2000) developed a performance assessment model for facility management
functions in hospitals. They identified several factors affecting the performance of hospital
buildings. Based on these factors, they developed a number of KPIs linking the performance of
facilities with revenue of the hospital. As such, their approach would be more appealing to
private hospitals because of its focus on revenue. Shohet (2006) developed a set of KPIs for
strategic maintenance management for a case study hospital. The aim was to use these KPIs as a
basis for selection, monitoring, and control of the hospital’s maintenance service suppliers. Van
Horenbeek and Pintelon (2014) provided a framework for developing KPIs for maintenance
management using analytic hierarchy process (AHP). Decomposing the maintenance
management issues into to a hierarchy of tactical and operational sub-issues and causes using
AHP provides a ranking for the root causes of performance and maintenance problems, which
assist in prioritizing maintenance strategies and activities.

13
 Integrated performance-based maintenance management is a method developed to
integrate indicators related to the performance and the efficiency of maintenance in hospital
buildings (Shohet, 2003b). These indicators are building performance indicator (BPI), manpower
sources diagram (MSD), maintenance efficacy indicator (MEI), and an organizational indicator
of maintenance unit (Shohet et al., 2003). Shohet and Lavy (2004b) also developed an integrated
healthcare facility management model (IHFMM) as a decision aid model to assist facility
managers in their tactical and strategic decision-making. It consists of five modules of
maintenance management, performance and risk management, energy and operations, business
management, renovation and development. However, only the first two modules were further
investigated and integrated to establish a performance measurement framework for FM
functions. Lavy and Shohet (2007b) asserted that their evaluation can be enhanced by
incorporating additional modules.

Similarly, Enshassi and El Shorafa (2015) suggested four KPIs for maintenance activities
of public hospital buildings in the Gaza Strip. These KPIs are BPI, MEI, annual maintenance
expenditure (AME) and urgent repair indicator (URI). The latter is an indicator which shows to
what extent the maintenance staffs are engaged in urgent repairs (Park and Augenbroe, 2003). It
is the ratio of urgent repairs by guest and in-house staff to the total number of repairs (Enshassi
and El Shorafa , 2015). Enshassi and El Shorafa (2015) calculated BPI based on an area-based
weighting method instead of the more common lifecycle costing (LCC) approach as a result of
lack of data on maintenance costs.

Ali and Wan Mohamad (2009) investigated maintenance management and its
performance in a public hospital in Malaysia. They defined these KPIs to assess the performance
of the hospital in terms of leadership; policies, plans, and procedures; training and orientation;
and service performance. Their findings point to some weaknesses related to maintenance
performance in hospitals, such as lack of policies, plans, and procedures to trigger improvement
of maintenance performance and also a lack of proper training and orientation for maintenance
personnel. They also highlighted the mismatch between contractual requirements and
organizational capabilities of maintenance management in hospitals.
There is a building performance assessment toolkit developed by the United Kingdom
National Health Service (UK NHS) according to Building Research Establishment

14
Environmental Assessment Method (BREEAM) called Achieving Excellence Design Evaluation
Toolkit (AEDET). This toolkit assists evaluating the design of healthcare facilities and buildings
to ensure their operational performance. In Australia, Talib et al. (2013) developed a framework
for measuring the performance of healthcare buildings. They considered function, societal and
environmental impacts, and service quality as the performance criteria for healthcare buildings
with maintenance unit as one of the very few components of the hospital that has direct influence
on all of these criteria.
Simulation is also used in order to provide an understanding of the future performance of
hospitals and their maintenance functions (Lavy et al., 2014a). Simulation is a useful tool to
generate and investigate different future scenarios for a system (such as a hospital) according to
past trends, current conditions as well as expectations about the future. It not only facilitates
long-term decision making and planning but also provides insights into understanding the impact
of such decisions and plans. In case of maintenance performance in hospitals, simulation
approaches were mostly developed to quantify the future trends of KPIs. In particular, simulation
is used to analyze maintenance expenditures in long term, and to ensure that they are below a
target, referred to as Condition Index (CI), while providing quality services according to
requirements and expectations (Montazer et al., 2003; Chen et al., 2003; Dessouky and Bayer,
2002; Lavy et al., 2014b).

Alzaben et al. (2014) conducted a study in Riyadh Military Hospital (RMH) and identified
a set of critical success factors (CSFs) for hospital maintenance management systems. They have
investigated and reviewed Total Preventive Maintenance (TPM), Reliability Centered
Maintenance (RCM) and Reliability Centered Failure Analysis (RCFA) and their benefits and
performance implications as three maintenance management strategies for healthcare facility
management (Alzaben et al., 2014).

Shohet et al. (2003) point to the fact that individual KPIs could not provide a complete
diagnosis of maintenance performance in hospitals. They argue that KPIs must be selected and
used according to hospitals’ maintenance priorities and by taking into account the criticality and
complexity of these activities. In addition, selecting an appropriate set of KPIs is influenced by
issues beyond the characteristics of a hospital building and extends to supply chain factors as

15
well as environmental, social and economic conditions and requirements (Alwaer and Clements-
Croome, 2010).

Enshassi and El Shorafa (2015) highlight the lack of systematic documentation and
scheduling of maintenance activities as the main difficulty in establishing a performance
evaluation in hospitals. Talib et al. (2013) emphasizes that the lack of a strategic view in
maintenance management of hospitals results in undervaluing and neglecting the importance of
developing useful and practical performance indicators with respect to quality, impact, and
efficiency of maintenance activities.
Fard et al. (2016) used discrete event simulation to evaluate the impact of home-hospital
care in reducing the emergency visits and crowdings. The patients and request resources were
modeled as a network of system entries. The bed-cleaning turnaround time is selected as an
indicator for the performance of emergency units. Liyanage and Egbu (2008) proposed a
performance management framework for facility management activities is hospitals. They used a
set of KPIs to generate performance monitoring and control indicators.
Reviewing the above literature, we can conclude that there are still gaps and
shortcomings when it comes to maintenance performance measurement in healthcare facilities.
Shohet (2006) mentioned the difficulty of establishing KPIs for complex buildings, such as
hospitals, due to the multitude and extreme variations in the scale of maintenance performance
parameters. Moreover, maintenance performance assessment needs to account for a combination
of qualitative and quantitative parameters, which some of them are readily measurable, such as
the number of patients served, and some are difficult to monitor such as patient satisfaction.
Also, the multitude of KPIs that exist in the literature requires a proper approach to select the
most appropriate ones for any particular hospital (Lavy et al, 2014b).
In summary, several studies have advocated development and use of performance
indicators as a means of improving the conditions of maintenance management in healthcare
facilities. Despite such a consensus, there are variations and disagreements on which indicators
could well represent the performance of maintenance activities as their impacts and requirements
extend into services of hospitals (which is varied in different hospitals) and are influenced by the
wider social and economic factors.

16
3- Information Technology and Decision-making
In a complex facility such as a hospital, a cost-efficient and reliable maintenance function
relies on advanced communication and information systems (Easman et al., 2008). However, the
information about various maintenance activities are generally fragmented and not well
documented and recorded in hospitals (Lucas et al., 2013). In addition, in maintenance
management of hospital buildings, facility managers are exposed to an extensive amount of
information related to buildings, operations, technologies, staff, and patients (Lucas et al., 2013).

The handling of such information is further aggravated by multidisciplinary nature of

maintenance decisions and by changes over the service life of healthcare facilities. This requires
the transfer of information from earlier phases of planning and design to later stages of operation
and maintenance (Becerik-Gerber et al., 2011). In this sense, many of the reviewed articles are
dealing with the use of information technologies and decision support systems in implementing,
facilitating and improving the maintenance management in hospitals.

Some of the above-mentioned issues could be addressed by FM information systems,

such as computerized maintenance management systems (CMMS) (Labib, 1998), electronic
document management systems (EDMS) (Koulopoulos and Frappaolo, 1993), energy
management systems (EMS) (Maghsoodlou et al., 2004) and building automation systems (BAS)
(Wong and Wang, 2005). In reality, these systems are not integrated and their data is fragmented
and thus not easily transmissible between systems. As such, in most cases, they need to enter the
data manually from one system to another one, which is time-consuming and insufficient
(Becerik-Gerber et al., 2011; Gallaher et al., 2004). Thus, we have an incomplete set of
information at any point of time that creates uncertainties and difficulties for maintenance
decision making (Deng, 2001; Goedert and Meadati, 2008).

Meng (2015) advocates that integrating IT in maintenance management in hospitals has

several benefits; such as cost savings, faster and easier communication, higher productivity, and
increased health and safety. In this regard, Sebastian (2011) implemented a building information
modeling (BIM) system in a hospital building in the Netherlands. He advocates that BIM
implementation contributes to improving change management capabilities of the maintenance
unit.

17
 There is an increasing interest in the use of artificial intelligence (AI) and information
communication and technology (ICT) techniques in the management of healthcare facilities
(Shohet and Lavy, 2004a). Shohet and Lavy (2004a) proposed a healthcare FM model that
incorporates ICT in facility management functions of hospitals. Lucas et al.(2013) suggested an
object-oriented model as a means of information management in the healthcare facilities. This
model is a BIM-based framework that could assist in tracking, storing and filtering information
during the lifecycle of healthcare facilities. The novelty of this model is that it integrates and
links facility information with clinical information which is generally separated in hospitals. The
proposed model includes process documentation, case analysis, information analysis, Unified
Modeling Language (UML) classification, test case analysis, prototype development, and
evaluation. One of the main benefits of this model is that it aims at minimizing the response time
to failure incidents in order to prevent or minimize damages to critical facilities of hospitals.
Irizarry et al. (2014) developed BIM-based approach as a means of monitoring the maintenance
tasks related to facility management in healthcare. They integrated an augmented reality (AR)
and BIM to build an ambient intelligent (AMI) environment.

IT could facilitate the exchange of information between different stages, departments and
parties involved in the maintenance process. As such, it could serve as a basis for informed
decision making in maintenance management of hospitals including staffing, scheduling, and
execution of maintenance activities (Warning and Wainwright, 2002). IT could well serve the
implementation of ERP systems in hospitals contributing to better planning and efficient
allocation of resources (Van Merodea et al., 2004).

Lavy and Shohet (2007a) developed an AI model to integrate facility service life, the
level of occupancy and maintenance expenditure as a decision aid for performance assessment of
maintenance units in hospitals. Their model is divided into three interfaces: input interface,
reasoning evaluator and predictor interface, and an output interface. The input interface designed
based on a deductive reasoning approach, which decomposes the available information into
several hierarchies from general facility information to case-specific information related to
buildings, systems, and components.

Ali and Hegazy (2014) developed a tri-level performance assessment framework for
healthcare facilities, which consists of hospital data structure, assessment criteria, and visual all-

18
onsite inspection. This methodology evaluates the performance of a healthcare facility based on
four KPIs; condition, level of service (LOS), sustainability, and risk. The study claims that the
proposed approach reduces time and cost of inspections and supports capital renewal decisions
by providing timely information about the facility and its assets.

Liberatore and Nydick (2008) reviewed the use of analytic hierarchy process (AHP) as a
decision-making tool in healthcare facilities management. The rationale behind their choice is
that in healthcare facilities management, and in particular in maintenance activities, we are
addressing several objectives such as cost, time, resources efficiency, etc. Therefore, MCDM
models such as AHP could assist in the decision-making process. In this sense, Lee and Kwak
(2011) proposed an integrated approach combining goal programming (GP) and analytic
hierarchy process (AHP) for establishing an optimal ERP system in healthcare facilities. They
addressed strategic goals of quality, cost, flexibility, and delivery of healthcare services while
choosing the plans that meet the hospital’s mission expressed via several criteria. Those are
expressed as financial requirements, manpower requirements, revenue requirements, capacity
requirements, and admission requirements. It is shown that adopting such an integrated approach
could enhance the satisfaction of patients and other stakeholders.

In most of the above studies, the facility information system is not linked to the patient
services, which makes it difficult to capture the impact of maintenance functions on core services
of the hospitals. In this sense, Mohammadpour et al. (2015) proposed a facility failure analysis
model linking facility failures to healthcare delivery process in a hospital. This model helps to
identify and rank the failures that have a critical impact on service delivery, which helps
prioritize planned or unplanned maintenance activities. In this regard, location, availability of
information, internal and external resources, required skills, the severity of failures, the level of
impact on patients and staff are the important findings from such an analysis (Mohammadpour et
al., 2015).

In summary, incorporating information technology (IT) is one of the main challenges in

managing and maintaining healthcare facilities. IT is integral to capturing, storing, sorting and
exchanging data for different maintenance activities. Informed decision-making improves the
performance of maintenance activities, increases the satisfaction of customers and reduces the

19
risk and the cost of failure. To address the above issues, a transition to real-time maintenance
decision-making is necessary.

Overall, this paper has identified available literature in the field of maintenance management for
healthcare facilities. We have reviewed strategic, tactical, and operational levels of facility
maintenance management in hospital buildings. We highlighted the issues related to maintenance
management functions in hospitals and reviewed the methods proposed in the literature to
address them. On that basis, we have identified the remaining issues and research gaps as relate
to maintenance management in hospitals. Table 5 provides a summary of methodologies,
findings and the identified gaps in the literature. We paid a particular attention to the role of IT
and decision support systems in coordinating and integrating the strategic plans of maintenance
management with operational objectives of costing, resource allocation, risk management, and
performance monitoring and evaluation. Figure 2 is summarizing the structure and contents of
our literature review.

At the end, it should be mentioned that we have created a database to organize the
reviewed references based on the proposed hierarchy in Excel 2013. We hyperlinked the titles to
their URL providing the opportunity to easily search the related references and have online
access to them via publishers’ websites. Furthermore, readers can filter references by using
keywords to arrive at a more focused list of references. Access to this database will be provided
upon request.

4- Conclusions
According to the literature review, several issues which affect facility maintenance management
in hospital buildings were identified, including budget limitations, high expenditures, criticality
of services, customer satisfaction, complexity of information and decision-making. To address
some of these issues, research has emerged in maintenance cost efficiency, maintenance resource
allocation, maintenance performance measurement, and maintenance strategic planning.

In this sense, we organized this paper into two sections; the first one provided a review of
maintenance strategic planning, maintenance costing, sourcing and contract management,
maintenance resource allocation, maintenance risk, and maintenance performance measurement.

20
The second section focused on the role of information technology and decision-making in
healthcare facilities maintenance management.

At the end, we should reiterate the fact that improving the performance of maintenance
functions in healthcare facilities not only leads to cost and resource efficiency gains but also
elevates the satisfaction of patients by increasing the quality and reliability of services. We have
identified several areas that are need of update and further research. The prioritization and
scheduling of maintenance activities in hospitals should be systematically linked through an
integrated model that takes into account the criticality of services, the age of facilities, and the
peak and base demands for this services. Further, maintenance management systems in hospitals
should go beyond assessing the performance based on the functionality of maintenance units and
should link the performance of the maintenance unit to its impact and contribution to energy
efficiency and environmental impacts of the hospital. In addition, the healthcare sector, due to its
criticality of services, should consider adopting availability-based maintenance strategies,
currently in practice in power industry, to ensure service continuity while avoiding over-
maintenance and maintenance budget allocation inefficiencies.

Acknowledment

The authors are very much thanlful to the editor and two anonymous reviewers for their
comemnts and suggestions that were very much helpful in improving the quality of the
manuscript.

References

Alexander, K. (1992), "Managing Quality, Value and Risk: An Introduction to Essential

Facilities Management", MBC Press in association with CFM, University of Strathclyde.
Glasgow.

Ali, M. and Mohamad Nasbi Bin Wan Mohamad, W. (2009), "Audit assessment of the facilities
maintenance management in a public hospital in Malaysia", Journal of Facilities
Management, Vol.7 No.2, pp.142-158.

21
Ali, A. and Hegazy, T. (2013), "Multicriteria Assessment and Prioritization of Hospital Renewal
Needs", Journal of Performance of Constructed Facilities, Vol. 28 No.3, pp. 528-538.

Alwaer, H. and Clements-Croome, D.J. (2010), "Key performance indicators (KPIs) and priority
setting in using the multi-attribute approach for assessing sustainable intelligent
buildings", Building and Environment, Vol.45 No.4, pp.799-807.

Alzaben, H., McCollin, C. and Eugene, L. (2014, June), "Maintenance Planning in a Saudi
Arabian Hospital", In Safety and Reliability, Taylor & Francis,Vol. 34 No. 2, pp. 25-40.

Al-Zubaidi, H. and Christer, A. H. (1997), "Maintenance manpower modelling for a hospital

building complex", European Journal of Operational Research, Vol.99 No.3, pp.603-
618.

Assaf, S., Hassanain, M. A., Al‐Hammad, A. and Al‐Nehm, (2011), "Factors affecting
outsourcing decisions of maintenance services in Saudi Arabian universities", Property
Management, Vol.29 No.2, pp.195 - 212.

Becerik-Gerber, B., Jazizadeh, F., Li, N. and Calis, G. (2011), "Application areas and data
requirements for BIM-enabled facilities management", Journal of construction
engineering and management, Vol.138 No.3, pp.431-442.

Ben-Daya, M., Ait-Kadi, D., Duffuaa, S.O., Knezevic, J. and Raouf, A. (2009), Handbook of
maintenance management and engineering, Vol. 7, Springer, London.

Boussabaine, H., Sliteen, S. and Catarina, O. (2012), "The impact of hospital bed use on
healthcare facilities operational costs: The French perspective", Facilities, Vol.30 No.1/2,
pp.40-55.

BS 3811:1993, British Standard Glossary of maintenance management terms in terotechnology.

Chan,. A. and Chan, A. P. (2004), "Key performance indicators for measuring construction
success", Benchmarking: An International Journal, Vol.11, pp.203-21.

Chen, D., Cao, Y., Trivedi, K. S. and Hong, Y. (2003), "Preventive maintenance of multi-state
system with phase-type failure time distribution and non-zero inspection time",

22
 International Journal of Reliability, Quality and Safety Engineering, Vol.10 No.03,
pp.323-344.

CHFM (Certified Healthcare Facility Manager) (2016), CANDIDATE HAND BOOK AND
APPLICATION, Conducted by the American Hospital Association Certification
Center,(accessed on http://www.aha.org/certifcenter/CHFM/index.shtml).

Chotipanich, S. (2004), "Positioning facility management", Facilities, Vol. 22 No.13/14, pp.364-

372.

Ciarapica, F.E., Giacchetta, G. and Paciarotti, C. (2008), "Facility management in the healthcare
sector: analysis of the Italian situation", Production Planning & Control, Vol.19No.4,
pp.327-341.

Deng, Z. M. (2001), "An application of the Internet-based project management system",

Automation in Construction, Vol.10 No.2, pp.239-246.

De Silva, N., Ranasinghe, M. and De Silva, C. R. (2012), "Risk factors affecting building
maintenance under tropical conditions", Journal of Financial Management of Property
and Construction, Vol.17 No.3, pp.235-252.

Dessouky, Y. M. and Bayer, A. (2002), "A simulation and design of experiments modeling
approach to minimize building maintenance costs", Computers & Industrial Engineering,
Vol.43 No.4, pp.423–36.

Diez , K. and Lennerts, K. (2009), "A process-oriented analysis of facility management services
in hospitals as a basis for strategic planning", Journal of Facilities Management, Vol.7
No.1, pp.52-60.

Enshassi , A. A. and El Shorafa , F. (2015), "Key performance indicators for the maintenance of
public hospitals buildings in the Gaza Strip", Facilities, Vol.33 No.3/4, pp.206 - 228.

Fard, J., Roper, K.O. and Hess, J. (2016), "Simulation of home-hospital impacts on crowding–
FM implications", Facilities, Vol.34 No.13/14, pp.748-765.

Flanagan, R., Norman, G. and Meadows, J. (1989), Life cycle costing: theory and practice.
Oxford: BSP Professional Books.

23
Franceschini , F., Galetto , M., Pignatelli , A., & Varett, M. (2003), "Outsourcing: guidelines for
a structured approach", Benchmarking: an International Journal, Vol.10, pp.246-60.

Gallagher, M. and Harlow, P. (1998), "Evolution of Facilities Management in the Health Care
Sector", Construction Paper, Vol.86, pp.1-8.

Gallaher, M.,O’Connor, A., Dettbarn, J. and Gilday, L. (2004), Cost analysis of inadequate
interoperability in the US capital facilities industry, National Institute of Standards and
Technology (NIST).

Garg , A. and Deshmukh, S. G. (2006), "Maintenance management: literature review and

direction", Journal of Quality in Maintenance Engineering, Vol.12 No.3, pp.205 - 238.

Goedert, J.D. and Meadati, P. (2008), "Integrating construction process documentation into
b+uilding information modeling", Journal of construction engineering and management,
Vol.134 No.7, pp.509-516.

Grimson, J. (2001), "Delivering the electronic healthcare record for the 21st century",
International journal of medical informatics, Vol.64 No.2, pp.111-127.

Gross, J. M. (2002), Fundamentals of preventive maintenance, AMACOM American

Management Association.USA.

Higgins, L.R., Mobley, R.K. and Smith, R. (2002), Maintenance engineering handbook,
McGraw-Hill.

Horner, R. M. W., El-Haram, M. A. and Munns, A. K. (1997), "Building maintenance strategy: a

new management approach", Journal of Quality in Maintenance Engineering, Vol.3
No.4, pp.273-280.

Hosking, J. E. and Jarvis, R. J. (2003), "Developing a replacement facility strategy: Lessons from
the healthcare sector", Journal of Facilities Management, Vol.2, pp.214-228.

Ikediashi, D. and Ekanem, A.M. (2015) "Outsourcing of facilities management (FM) services in
public hospitals", Journal of Facilities Management, 13(1), pp. 85–102.

24
Ikediashi, D.I. and Ogunlana, S.O. (2015), Significant risk factors associated with facilities
management (FM) outsourcing: A study on Nigeria’s public hospitals", Engineering,
Construction and Architectural Management, Vol.22 No.6, pp.771-796.

Johnson, M., Clayton, R., and Song, Y. (1999), "Addressing the Information Needs of Facility
Managers", Durability of Building materials and Components, Vol.8, pp.2441-2451.

Kirk, S.J. and Dell'Isola, A.J. (1995), Life cycle costing for design professionals, The National
Academies of Sciences, Engineering, and Medicine.

Koulopoulos, T. M. and Frappaolo, C. (1993), Electronic document management systems: a

portable consultant, McGraw-Hill, Inc, New York, NY, USA.

Kumar , U., Galar, D., Parida, A., Stenström, C. and Berges, L. (2013), "Maintenance
performance metrics: a state-of-the-art review", Journal of Quality in Maintenance
Engineering, Vol.19 No.3, pp.233-277.

Kutucuoglu, K. Y., Hamali, j., Irani, Z. and Sharp, J. M. (2001), "A framework for managing
maintenance using performance measurement systems", International Journal of
Operations & Production Management, Vol.21 No.1/2, pp.173-195.

Labib, A. W. (1998), "World-class maintenance using a computerized maintenance management

system", Journal of Quality in Maintenance Engineering, Vol.4 No.1, pp.66 - 75.

Lavy, S., Garcia, J. A., Scinto, P. and Dixit, M. K. (2014a), "Key performance indicators for
facility performance assessment: simulation of core indicators", Construction
Management and Economics, Vol.32 No.12, pp.1183-1204.

Lavy, S., A. Garcia, J. and K. Dixit, M. (2014b), "KPIs for facility's performance assessment,
Part I: identification and categorization of core indicators", Facilities, Vol.32 No.5/6,
pp.256-274.

Lavy, S., & Shohet, I. M. (2007a), "Computer- Aided Healthcare Facility Management", Journal
of Computing in Civil Engineering, Vol.21, pp.363-372.

25
Lavy, S., & Shohet, I. M. (2007b), "A strategic integrated healthcare facility management
model", International Journal of Strategic Property Management, Vol.11 No.3, pp.125-
142.

Lavy, S. and Shohet, I. M. (2010), "Performance-based facility management-an integrated

approach", International Journal of Facility Management, Vol.1 No.1.

Lavy, S., Garcia, J. A. and Dixit, M. K. (2010), "Establishment of KPIs for facility performance
measurement: review of literature". Facilities, Vol.28 No.9/10, pp.440 - 464.

Lee, C. W. and Kwak, N. K. (2011), "Strategic Enterprise Resource Planning in a Health-Care

System Using a Multicriteria Decision-Making Model", Journal of medical systems,
Vol.35, pp.265–275.

Lennerts, K., Abel, J., Pfründer, U. and Sharma, V. (2005), "Step-by-step process analysis for
hospital facility management: An insight into the OPIK research project", Facilities,
Vol.23 No.3/4, pp.164-175.

Leung, M. Y., Chan, I. Y. S. and Olomolaiye, P. (2013), "Relationships between facility

management, risks and health of elderly in care and attention homes", Facilities, Vol.31
No.13/14, pp.659-680.

Liyanage, C. and Egbu, C. (2008), "A performance management framework for healthcare
facilities management", Journal of Facilities Management, 6(1), pp. 23–36.

Liberatore, M. J. and Nydick, R. L. (2008), "The analytic hierarchy process in medical and
health care decision making: A literature review", European Journal of Operational
Research, Vol.189 No.1, pp. 194-207.

Liu, L. Y., Stumpf, A. L., Kim, S. S. and Zbinden, F. M. (1994, June), "Capturing as-built
project information for facility management", In Computing in Civil Engineering, ASCE
, pp. 614-621.

Loosemore, M. and Hsin, Y. Y. (2001), "Customer-focused benchmarking for facilities

management", Facilities, Vol.19 No.13/14, pp.464-457.

26
Lucas, J., Bulbul, T. and Thabet, W. (2013), "An object-oriented model to support healthcare
facility information management", Automation in Construction, Vol.31, pp.281-291.

Maghsoodlou, F., Masiello, R. and Ray, T. (2004), "Energy management systems", IEEE Power
and Energy Magazine, Vol.2 No.5, pp.49-57.

May, D. and Clark, L. (2009), "Achieving patient‐focused maintenance services/systems",

Journal of Facilities Management, 7(2), pp. 128–141.

May, D. and Pinder, J. (2008), "The impact of facilities management on patient outcomes",
Facilities, Vol 26 No.5/6, pp.213-228.

Meng, X. (2015), "Facilities management: tracing its development trajectory", Property

Management, Vol.33 No.3, pp.212-223.

Menge, X. and Mingue, M. (2011), "Performance measurement in facilities management: a

comparative study", Facilities, Vol.29 No.11/12, pp.472-484.

Mintzberg, H. (1981), Organization design: fashion or fit? , Graduate School of Business

Administration, Harvard University.

Mohammadpour, A., Anumba, C. J., Bulbul, T., Messner, J., Singh, G. and Singh, R. (2015),
"Impact Analysis of Facility Failures on Healthcare Delivery Process: Use Case–Driven
Approach", Journal of Performance of Constructed Facilities, pp.040150931-10.

Montazer, M. A., Ece, K. and Alp, H. (2003), "Simulation modeling in operations management:
a sampling of applications", In 14th annual conference of the production and operations
management society, Savannah, GA.

Mosadeghrad, A. M., Ferlie, E. and Rosenberg, D. (2011), "A study of relationship between job
stress, quality of working life and turnover intention among hospital employees", Health
Services Management Research, Vol.24 No.4, pp.170-181.

Nesje, A. (2002), "Management, operation and maintenance costs of hospital buildings", In

Proceedings of the International Federation of Hospital Engineering, Bergen, pp. 290-
96.

27
O'Donovan, M. (1997), "Risk management and the medical profession", Journal of Management
Development, Vol.16, pp.125-33.

Okoroh, M. I., Gombera, P. P. and Ilozor, B. D. (2002), "Managing FM(support

services);business risks in the healthcare sector", Facilities, Vol.20, pp.41-51.

Irizarry, J., Gheisari, M., Williams, G. and Roper, K. (2014), "Ambient intelligence
environments for accessing building information: A healthcare facility management
scenario", Facilities, Vol. 32 No. 3/4, pp.120-138.

Parida, A. and Kumar, U. (2006), "Maintenance performance measurement (MPM): issues and
challenges", Journal of Quality in Maintenance Engineering, Vol.12 No.3, pp.239-251.

Park, C. S. and Augenbroe, G. (2003), "A preliminary survey on maintenance performance

indicators and planning steps", Survey on Maintenance Performance Indicators and
Planning Steps, College of Architecture, Georgia Institute of Technology, Atlanta,
Georgia, USA, pp.23.

Pedersen, M. K. and Larsen, M. H. (2001), "Distributed knowledge management based on

product state models—the case of decision support in health care administration",
Decision Support Systems, Vol.31 No.1, pp.139-158.

Powell, A. (2002), "Contracting out hospital services, Proceedings of the International

Federation of Hospital Engineering, Berge, pp. 154-162.

Pullen, S., Atkinson, D. and Tucker, S. (2000), "Improvements in benchmarking the asset
management of medical facilities", Proceedings of the International Symposium on
Facilities Management and Maintenance, Brisbane, (pp. 265-71).

Rajagopal, P. (2002), "An innovation-diffusion view of implementation of enterprise resource

planning (ERP) systems and development of a research model", Information &
Management, Vol.40 No.2, pp.87-114.

Rani, N. A. A., Baharum, M. R., Akbar, A. R. N. and Nawawi, A. H. (2015), "Perception of

Maintenance Management Strategy on Healthcare Facilities", Procedia-Social and
Behavioral Sciences, Vol.170, pp.272-281.

28
Rees, D. (1997), "The current state of facilities management in the UK National Health Service:
an overview of management structures", Facilities, Vol.15 No.3/4, pp.62-5.

Rees, D. (1998), "Management structures of facilities management in the National Health

Service in England: a review of trends 1995-1997", Facilities, Vol.16 No.9/10, pp.254-
61.

Roper, K.O. and Payant, R.P. (2014), The Facility Management Handbook. AMACOM
American Management Association, USA.

Sebastian, R. (2011), "Changing roles of the clients, architects and contractors through BIM",
Engineering, Construction and Architectural Management, Vol.18 No.2, pp.176-187.

Sharma, V., Abel, J., Al-Hussein, M., Lennerts, K. and Pfründer, U. (2007), "Simulation
application for resource allocation in facility management processes in hospitals",
Facilities, Vol.25 No.13/14, pp.493-506.

Shohet, I. M. (2003a), "Building evaluation methodology for setting maintenance priorities in

hospital buildings", Construction Management and Economics, Vol.21 No.7, pp.681-692.

Shohet, I. M. (2003b), "Key performance indicators for maintenance of health‐care facilities",

Facilities, Vol. 21 No.1/2, pp.5 - 12.

Shohet, I. M. and Lavy, S. (2004a), "Healthcare facilities management: state of the art review",
Facilities, Vol.22 No.7/8, pp.210-220.

Shohet , I. M. and Lavy, S. (2004b), "Development of an integrated healthcare facilities

management model", Facilities, Vol.22 , pp.129-140.

Shohet, I. M., Lavy-Leibovich, S. and Bar-On, D. (2003), "Integrated maintenance monitoring of

hospital buildings", Construction Management & Economics, Vol.21 No.2, pp.219-228.

Shohet, I. M. and Nobili, L. (2016), "Enterprise resource planning system for performance-
based-maintenance of clinic", Automation in Construction, Vol.65, pp.33–41.

Shohet, I. M. (2006), "Key performance indicators for strategic healthcare facilities

maintenance", Journal of Construction Engineering and Management, Vol.132 No.4,
pp.345-352.

29
Sliteen, S., Boussabaine, H. and Catarina, O. (2011), "Benchmarking operation and maintenance
costs of French healthcare facilities", Journal of Facilities Management, Vol.9 No.4,
pp.266-281.

Sliteen, S. and Catarina, O. (2010), "Benchmarking: Strategies to Analyze Operation and

Maintenance Cost of Healthcare Facilities". In W070-Special Track 18th CIB World
Building Congress May 2010, Salford, United Kingdom, pp.192-201.

Stower, S. (1998), "Measuring risk in a children’s unit: developing a local strategy for health,
safety and risk management at Queen’s Medical Centre, Nottingham", International
Journal of Health Care Quality Assurance , Vol.11 No.7,pp. 232 - 237.

Straub, A. (2009), Cost savings from performance‐based maintenance contracting. International

Journal of Strategic Property Management, Vol.13 No.3, pp.205-217.

Straub, A. and van Mossel, H.J. (2007), "Contractor selection for performance‐based
maintenance partnerships", International Journal of Strategic Property Management,
Vol.11 No.2, pp.65-76.

Sullivan, G.P., Pugh, R., Melendez, A.P. and Hunt, W.D. (2004), Operations and Maintenance
Best Practices: A Guide to Achieving Operational Efficiency, Release 2.0, Pacific
Northwest National Laboratory (PNNL) for the Federal Energy Management Program
(FEMP),U.S. Department of Energy(DOE).

Talib, Y., Yang, R. J. and Rajagopalan, P. (2013), "Evaluation of building performance for
strategic facilities management in healthcare: A case study of a public hospital in
Australia", Facilities, Vol.31 No.13/14, pp.681-701.

Umeh, J.C. (1994), "Healthcare financing in the Kingdom of Saudi Arabia: a review of the
options", World hospitals and health services: the official journal of the International
Hospital Federation, Vol.31 No.2, pp.3-8.

Van Horenbeek, A. and Pintelon, L. (2014), "Development of a maintenance performance

measurement framework using the analytic network process (ANP) for maintenance
performance indicator selection", Omega, Vol.42 No.11, pp.33-46.

30
Van Merode, G. G., Groothuis, S. and Hasman, A. (2004), "Enterprise resource planning for
hospitals", International Journal of Medical Informatics, Vol.73 No.6, pp.493-501.

Ventovuori, T., Lehtonen, T., Salonen, A. and Nenonen, S. (2007), "A review and classification
of academic research in facilities management", Facilities,Vol.25 No.5/6, pp.227-237.

Wagstaff, T. (1996), "Productive use of IT in support of FM solutions", Facilities, Vol.14

No.1/2, pp.43-46.

Warning, T. and Wainwright, D. (2002), "Enhancing clinical and management discourse in ICT
implementation", Journal of management in Medicine, 16(2/3), pp.133-149.

Waterman, L. (1995), "Health and safety risk assessments in the health sector", Facilities, Vol.13
No.2, pp.22-25.

Wong, J. K., Li, H. and Wang, S. W. (2005),“Intelligent building research: a review”,

Automation in Construction, Vol.14 No.1, pp.143-159.

31
Figure 1 - Proposed hierarchy of Maintenance management

32
Figure 2 – Structure of the literature review and the related topics

33
 Table 1- A summary of related literature review papers

Year Author Title Journal

1998 Rees Management structures of facilities
management in the National Health
Facilities
Service in England: a review of trends
1995-1997.
2004 Shohet and Healthcare facilities management: state
Facilities
Lavy of the art review.
2006 Garg and Maintenance management: literature Journal of Quality
Deshmukh review and directions. in Maintenance
Engineering
2007 Ventovuori, A review and classification of
Lehtonen, Salonen academic research in facilities Facilities
and Nenonen management.
2010 Lavy, Garcia and Establishment of KPIs for facility
Dixit performance measurement: review of Facilities
literature.
2013 Kumar, Galar, Maintenance performance metrics: Journal of Quality
Parida, Stenström, state-of-the-art review. in Maintenance
and Berges Engineering

Table 2 - Keywords used in the literature

Keyword Frequency
Facility 43
Hospital/Healthcare 43
Maintenance 35
Performance 32
Source 12
Risk 12
Cost 11
Information 10
Decision-Making 7
Review 7
Case Study/Case Report/Use 5
Case
Simulation 4
Strategy 3
Contract 2
Survey 2
Optimization 1

34
 Table 3- Distribution of the literature in related journals

2006 2007- 2012- Total

Journal and 11 16
before
Facilities 10 5 7 22
Journal of Facilities Management 1 5 1 7
Automation in Construction 2 - 2 4
Construction Management and Economics 2 - 2 4
Journal of Quality in Maintenance Engineering 3 - 1 4
Journal of Construction Engineering and Management 1 2 - 3
Benchmarking: an International Journal 2 - - 2
Journal of Performance of Constructed Facilities - - 2 2
Engineering, Construction and Architectural Management - 1 1 2
European Journal of Operational Research 1 1 - 2
International journal of medical informatics 2 - - 2
International Journal of Strategic Property Management - 2 - 2
Property Management - 1 1 2

Table 4- Distribution of the literature in each subject category

Topics References
Maintenance strategies 12
Maintenance cost, sourcing, and contract management 21
Resource allocation 8
Maintenance risk management 12
Maintenance performance measurement 20
Information technology and decision-making 23

35
 Table 5 – Summary of the methodologies, findings and identified gaps in the literature
Identified research
Topics Authors, Year Methodology Findings
gaps
Shohet and • Limited research
Literature review Developed the Pentagon of healthcare FM
Lavy, 2004 reported on
Maintenance strategies
Investigated relationship between maintenance strategy maintenance planning
Rani et al., 2015 Questionnaire, survey
and end-user in hospital buildings
Investigated relationship between the facilities .
Loosemore and Data collection and semi-
management and the business objectives of the • Need to further
Hsin, 2001 structured interviews
organization research on measuring
and quantifying the
Diez and Data collection from four effect of maintenance
Developed a model for cost allocation of FM services.
Lennerts, 2009 German hospitals in healthcare
facilities.
Sliteen et al., Literature review, cases of Identified cost per bed ratio as an efficient metric to
2011 health facilities in France classify performance of healthcare facilities.
• Focus on identifying
Boussabaine et Data collection from Demonstrated the effects of medical activities on the the factors that affect
al., 2012 hospital facilities in Paris operation and maintenance cost of hospital.
the cost of
Questionnaire survey, maintenance instead
Assaf et al., Identified the factors influencing the decision to
literature review, cases in
Maintenance cost, sourcing, and contract management

2011 outsource maintenance services. of developing

the Saudi Arabia frameworks to
Al-Zubaidi and optimize these
Simulation Provided a manpower model for building maintenance.
Christer, 1997 expenditures.
Shohet, et al., Literature survey, Examined performance versus maintenance
2003 statistical analysis of data expenditures, Developed additional KPIs. • Limited research on
Developed a simulation model to analyze outsourcing addressing the
Franceschini et
Benchmarking, simulation decisions. mismatch between the
al., 2003
financial resources
Developed an evaluation methodology for the building’s available for
Shohet 2003a Surveys, KPIs
condition before and after maintenance or rehabilitation. maintenance in
Ciarapica et al., Identified the relevant variables for the outsourcing hospitals and the
Interviews expectations and
2008 decision-making process in hospitals.
Ikediashi and Surveyed hospitals to investigate their experience with requirements.
Questionnaire survey
Ekanem, 2015 outsourced FM
Case study, questionnaires, Identified contractor’s service performance as a major • Limited research to
Ali et al., 2009 identify the
interviews issue in maintenance outsourcing contracts.
Straub. and van Literature review, Developed a performance-based contract mechanism to relationship between
Mossel, 2007 interviews select an outsourcing contractor. cost, composition of
Data collection, Current in-house and
Alzaben et al., Reality Tree (CRT) and Identified the critical success factors (CSFs) in outsourced personnel,
2014 Thinking Process (TP), maintenance management. and contract
Theory of Constraints
36
 (TOC).

Literature review,
Shohet and questionnaire, inference
Nobili, 2016 engine, inferential
statistical analysis
Multi-criteria decision-
making (MCDM), Goal
Lee and Kwak,
Maintenance resource allocation
programming(GP),
2011
Analytical hierarchy
process (AHP)
Rajagopal, 2002 Case study
Lean Principles,
Sharma et al., Simulation, Data
2007 collection, case study of
hospitals in Germany
Data collection, Linear
Lennerts et al., regression, data analysis,
2005 case study of a hospital in
Germany
O'Donovan,
Case study
1997
Waterman, 1995 Surveys
Literature review,
Okoroh et al., meetings and interviews
2002 with facility managers of
Maintenance risk management
Developed a performance-based model by integrating
KPIs into an enterprise resource planning (ERP) system
for the maintenance of public clinic facilities.
• Limited research on
the customization and
Developed an integrated multi-criteria decision-making
implementation of
model to implement ERP for healthcare planning.
ERP systems for
health care
Investigated the implementation of ERP systems in applications.
healthcare sector
• Few available
Provided an optimization and simulation resource approaches developed
allocation framework. to optimize resource
allocation and
planning for
Provided a model to seek optimization of FM processes maintenance
through cost allocation and efficiency of performance. management in
hospital facilities
Emphasized the necessity of the risk management in
hospitals.
Investigated the FM related risks in healthcare sector. • Limited literature on
identification,
evaluation, and
Identified and classified the FM risk factors in National management of risks
Health Service hospitals. associated with

hospitals, case study maintenance

Collecting information functions in hospitals
using a
Prioritized the risk management activities in hospitals
Wagstaff, 1996 facilities management
considering cost, service quality, and quantity. • Very limited research
information
on reliability analysis
system
of hospital facilities
Lavy and Developed an integrated performance-based facility
Case study
Shohet, 2010 management for hospitals.
• Need to more
De Silva et al., Identified the risk factors associated with maintenance of research on
Survey
2012 high‐rise buildings. identifying and
Ikediashi and Questionnaire survey, case quantifying the
Ranked the risk factors in FM outsourcing.
Ogunlana, 2015 study, interview vulnerabilities of
Questionnaires, Pearson maintenance
Leung et al., correlation, and partial functions in hospitals
Identified risk profile of FM components
2013 correlation analyses, a case
study of care and attention

37
 homes
Parida and Identified the issues and challenges associated with
Multiple criteria analysis
Kumar, 2006 MPM.
Literature review, expert Compared performance measurement: using the Key
Menge. and
interview and performance indicators (KPI), the Balanced Scorecard
Mingue, 2011
questionnaire survey (BSC), and the Business Excellence Model (BEM).
Chan and Chan, Literature review, case Developed the methodology for measuring project
2004 study, KPIs performance for construction project.
Benchmarked the asset management of medical facilities,
Pullen et al., identified factors affecting the performance of hospital
Benchmarking • Absence of industry-
2000 buildings, developed KPIs to link the performance of
facilities with revenue of the hospital. wide benchmarks and
Field surveys, statistical Developed a set of KPIs for monitoring the performance, KPIs for measuring
Shohet, 2006 the performance of
analyses, case studies maintenance, and cost effectiveness of hospital facilities.
Van Horenbeek hospital buildings
Application of ANP Developed a decision support for implementation of a
and Pintelon,
Maintenance performance measurement

methodology customized MPM system. • Limited research on

2014
Case study, data
Liyanage and
collection, statistical
Egbu, 2008
analysis
Shohet, 2003a Surveys, KPIs
Shohet et al., Literature survey,
2003 statistical analysis of data
Survey among acute care
Shohet. and facilities in Israel;
Lavy, 2004 statistical analysis of the
data
Enshassi and El Case study of Gaza public
Shorafa, 2015 hospital buildings
Ali and Wan
Case study of a public
Mohamad,
hospital in Malaysia
(2009)
May & Clark, Questionnaire and
2009 statistical analysis
Case study of a public
hospital in Australia,
Talib et al., 2013
questionnaire, survey,
statistical analysis
Lavy et al., 2014 Simulation
understanding the
Developed a performance analysis framework for case operational issues in
study hospitals using KPIs establishing KPIs for
Developed a methodology to evaluate the building’s maintenance in
complex hospitals
condition during maintenance or rehabilitation.
Compared performance versus maintenance expenditure
• Very limited research
of hospitals, developed additional KPIs.
on implementation of
the KPIs such that to
account for variations
Developed an integrated model for healthcare FM.
in characteristics of
hospital facilities
Investigated KPIs for performance and expenditures
assessment. • Limited research on
measurement of
Identified weaknesses related to maintenance
performance for
performance.
outsourced services in
Investigated the maintenance team perception about their hospitals.
performance and its impact on patients’ satisfaction and
well-being
Develop a framework for measuring performance.
Developed a simulation tool for
decision-making in maintenance and replacement of
building systems
38
 Discrete-event simulation, Developed a discrete event simulation model for patient
Fard et al., 2016 Data collection from a flow, resource allocation, and performance monitoring of
case hospital emergency departments.
Ali and Hegazy, Data collection, survey, Developed a performance assessment framework for
2013 multiple criteria analysis healthcare facilities
Chotipanich, Proposed a decision making framework for improving
Literature review
2004 FM position in hospitals
Lucas et al., Developed an object oriented model to integrate facility
Case study, BIM • Limited research has
2013 information with clinical information
Data collection via been conducted to
Information technology and decision-making

Becerik-Gerber interviews, expert Identified potential application areas, benefits, and develop and
et al., 2011 interviews, online survey barriers of implementing BIM in FM implement decision
support systems
Criteria analysis, decision Developed a maintenance program to crafted to specific
Labib, 1998 mapping, and decision link preventive maintenance and emergency needs of maintenance
support maintenance. management units in
Meng, 2015 Semi-structured interview hospitals
Overviewed the issues related to implementation of BIM
Sebastian, 2011 Desk research • The absence of
in hospital buildings.
Lavy and Developed a decision support system for healthcare maintenance
Decision support system functions and issues
Shohet, 2007 facility management
Liberatore, and from most reported
Literature review A review of applications of AHP to health care FM management
Nydick, 2008
Investigated the interactions between facility failures and information systems
Mohammadpour Case-study, scenario developed for
the healthcare delivery process
et al., 2015 analysis hospitals.
Developed a BIM-based approach to improve
Mobile augmented reality
performance of facility mangers in maintenance tasks,
Irizarry et al., (MAR) and building
Provided a communication environment for
2014 information modeling
geographically distributed stakeholders to provide input
(BIM)
for FM activities.

39

View publication stats