DESIGN & CONSTRUCTION
Honing design to improve from one build to the next
In the first half of a two-part article, Consultant Medical Microbiologist, Dr Michael Weinbren, head of Estates Risk and Environment at Belfast Health and Social Care Trust, George McCracken, Susanne Lee of independent microbiology consultancy, Leegionella, and Consultant Microbiologist at NHS Greater Glasgow and Clyde, Dr Teresa Inkster, argue that ensuring patient safety in new healthcare facilities requires a markedly different approach to design and construction. They advocate ‘no longer blindly following guidance’, designing with patient safety uppermost, heeding lessons from past projects – and especially unsuccessful ones, and ‘front-loading’ projects at concept stage with risk identification and consideration.
While dangers are recognised on the construction site, a safety culture for occupants about to enter a new building is conspicuous by its absence. The risks emanating from design, construction, and commissioning of a new healthcare facility where the occupants are particularly vulnerable is causing death and patient harm on a scale of magnitude higher than on the construction site, yet this largely goes unrecognised. This is evidenced by the multitude of reports documenting patient infections from the built environment. The situation is further complicated by the very fabric of our hospital buildings driving antimicrobial resistance – the legacy of which threatens the future existence of many of the modern developments in medicine. Building occupant safety resides in a
bygone era lacking a health and safety culture, although perversely the concept of the built environment affecting occupant safety dates back to Florence Nightingale. When projects go wrong it is very easy
to blame a particular group of individuals, but in most instances, this would be totally incorrect. Understanding the basis for the failures is key to improving patient safety. The New Hospital Programme (NHP) is in a privileged position to implement unprecedented change to improve patient safety and change the way the construction industry works. This article examines why this should be the case, and the requirement for change.
Big headline stories Recent issues with new hospitals making headline reading (Glasgow, Edinburgh, Papworth, Belfast) are too common, especially given that the number of new facilities under construction at any time is relatively small. The cost to society includes loss of life (largely due to avoidable infection), and financial (remedial actions, increased length of stay, litigation), the latter becoming a drain on NHS resources for the lifetime of the building. However, there is a much bigger
problem (largely unrecognised) affecting every hospital, causing patient harm including deaths, and driving antimicrobial resistance. Whilst preventable, it first requires there to be recognition of the problem. History shows that major loss of life can occur in a variety of arenas – which either goes unnoticed, or is in some way accepted until a triggering event occurs driving change.
The built environment and patient (occupant) ill health Florence Nightingale is credited as being the first person to make the link between the built environment and patient ill- health – in her book ‘of notes on hospitals’ published in 1859. The first paragraph reads: ‘It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large, crowded cities, is very much
Figure 1: Safety culture in a new-build project primarily covers those working on the construction site. When deaths or injuries occur related to construction activities it is usually patently obvious to those in the vicinity (unless there are built-in delays such as occur with exposure to asbestos). Compare this with those about to occupy the building, where no equivalent safety culture exists – including hospitals which house highly vulnerable populations susceptible to microorganisms, where infection and resultant death is not uncommon. Avoidable deaths originating from the built environment (due to poor design, construction, or commissioning) do not stand out in such an arena. Disease and death originating from the built environment are largely not identified, allowing the healthcare facility to become a serial killer.
March 2024 Health Estate Journal 29
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