DESIGN & CONSTRUCTION Guidance and Building Compliance Standards
n Compliance with these documents is not delivering safe buildings. n Understanding and identification of risks affecting patient safety are not sufficiently prioritised.
Design and Construction Practice
n Patient safety is not culturally embedded in the design and construction process. n Construction of healthcare facilities is viewed and managed in the same manner as any other project.
Assurance Processes
n Communication and engagement on the importance of patient safety is not sufficiently embedded in the project assurance processes.
n Assurance on patient safety exists only in the world of paper, not in the real world of design and construction processes.
Capability Gaps
n A key gap is around competency, skills, knowledge, and behaviours. n A gap in understanding of patient safety within the design and construction processes.
Support n A lack of supported learning and supported accountability within project governance and management means patient safety is not the highest priority for everyone.
Procurement
n Failure to recognise how engaged and effective procurement contributes to patient safety through the de-risking of projects
Early intervention n A lack of understanding and consideration of risks at the concept of each project creates the false environment either that no risks exist, or that they are minimised, to the detrimental impact of patient safety.
Table 1: Issues with the current system of healthcare design, construction, and commissioning.
Appointing Infection Control personnel Infection control personnel may be appointed as they have been trained in the built environment. However it is exceedingly unlikely that one person has all the necessary expertise, requiring at least two individuals – one to cover water / wastewater, and another ventilation etc. The same would apply to an AE(W); the expectation that they would know everything about water / wastewater systems is unreasonable. Having several AE(W)s in the Water Safety Group of a large project to ensure expertise in all areas should become the norm. A project should have a safety groups relevant to each engineering discipline. Just because someone is already part of the project, must not mean that they are automatically accepted onto a group without checking their expertise.
Group competence Even with all the assembled skills, a group can be dysfunctional. A supportive learning environment where individuals understand the importance of group dynamics, where each person’s views are valid, is equally important as individual competence. For someone to feel confident to say they do not have the requisite knowledge to make a decision is essential. Being able to say this is a strength, not a weakness. (Not disclosing that something is outside one’s remit is
30 Health Estate Journal April 2024
a weakness.) The supportive learning environment should create a system where anyone can access anyone else’s expertise to get answers, thereby ensuring that their competence is utilised, rather than just another paper exercise. Design teams normally model a new
water system based around a specification and guidance. A risk-based approach is quite different. The question or challenge to the design team now becomes ‘How are you going to ensure that the design of this new water system is safe?’ This is a massive departure in culture, focusing the work on safety.
Developing a methodology to mitigate risks Table 1 highlights some of the issues with the current system of healthcare design, construction, and commissioning. The following example of moving to a risk- based approach is based around water safety, but is equally applicable to all the other engineering disciplines. 1. At the inception of a project all parties need to be trained in why and how a risk-based approach is required to
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ensure occupant safety and project success.
2. The Chief Executive of the Trust should be appointed as Duty-Holder for the project, holding accountability for safety and outcomes.
3. The first assessment is whether water/ wastewater is a risk in the new-build process? – inevitably for a new hospital the answer will be ‘yes’.
4. What high-risk patient groups will be housed in the facility?
5. A project Water Safety Group will be established consisting of architect, design team, and construction personnel, as well as the required Trust members of the Water Safety Group.
6. Members of the project Water Safety Group to be appointed on the basis of expertise and training rather than job title (job title does not necessarily guarantee individuals with the requisite expertise).*
7. A gap analysis is undertaken next to ensure that there are individuals with the required expertise and sufficient time available to fully partake in the project.
8. A Trust Board member to be appointed as director responsible for water safety. This individual is there to support the project Water Safety Group, with regular dialogue between the two parties. Any difficulties which the project Water Safety Group is unable to resolve are to be escalated to the director responsible for water safety, who then escalates within the senior project team. The director will need to receive specific training on what the risks are, what the project Water Safety Group should be delivering, and how to monitor their performance.
9. The project Water Safety Group should anticipate all the potential risks across all the building stages (design, construction, commissioning, and occupation) at the inception of the project, in order that all the necessary mitigations are included within the final business case.
10. Once the risks have been identified, the skills of the individuals around the table can be fully utilised.**
11. The periphery of the water system, arbitrarily defined as the last 2 m of pipework-connected devices and the associated wastewater system, need to be recognised as an area requiring specialist expertise and training. The majority of the water/wastewater
Disturbingly, the routine barriers put in place to prevent transmission of infection are ineffective in controlling such transmission from the built environment, in particular by water or wastewater
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