Although most commonly used as smaller mobile care units, such as MRI rooms, applications range from dialysis facilities and pharmacies to surgical suites, or even emergency care units rapidly deployed in the aftermath of a natural disaster.

“This option provides a great opportunity for community hospitals to add fixed imaging services in a rapid fashion and at a palatable price point,” relates Steven Wagman, vice-president and practice director for Enterprise Solutions, Malvern, Pennsylvania, and Lynette Sroka, AIA, senior manager, design and construction Services, Cary, North Carolina, both with Siemens Medical Solutions, USA.

Similarly, Brian Johnson, president, Serenus Johnson Portables, LLC., Bay City, Michigan, points out, “We have found that modular construction is an economical solution to permanent construction or when temporary (one to three years) usage is required. Modular is a quick way to get up and going now that codes can be met with a little pre-planning and creative engineering.”

Of course, temporary can easily translate to “permanent,” as Michael P. Sheerin, PE, LEED AP, principal, director of healthcare engineering, TLC Engineering for Architecture, Orlando, has witnessed time and time again. Not interested in giving up space once it's created, such “temporary” modulars frequently end up serving a variety of changing spaces needs for a decade or more.

Some such uses have included administrative or clinic swing space during hospital renovations, or as temporary expansion space. For one recent TLC project, a modular unit was actually turned into a kitchen while the main kitchen was renovated.

The basics

Essentially, these units are built off-site in the factory under controlled conditions. Consequently, there's a higher level of quality control, material shortages are reduced, and weather delays are avoided, according to Wagman and Sroka.

“Mechanical and electrical infrastructures can be installed and tested offsite, creating process efficiencies and improved functionality,” agrees Michele Cunningham, vice-president, marketing and business development, Williams Scotsman, Baltimore. “For example, when constructing a modular diagnostic imaging solution, the scan room can be encapsulated into one module, allowing for the complex shielding, electrical, and mechanical connections to be made in the factory.”

Since construction phases occur simultaneously, as opposed to sequentially, site work and off-site construction proceed concurrently, essentially cutting the construction timeline in half.

Of course, speed to occupancy quickly translates to the bottom line, as was the case with the recent modular construction of a digital mammography center for Massachusetts' Cambridge Hospital. According to Cliff Cort, president, Triumph Modular, Littleton, Massachusetts, whose company designed the unit, the facility was up and running six months ahead of schedule, enabling the hospital to cash in on tens of thousands of dollars every week in revenues. (For more, see sidebar, “Drop In Modular for Cambridge Hospital,” on pg. 37.)

Photo courtesy of Triumph Modular

In addition, the plug-and-play nature of the units makes swapping in new equipment more feasible and timely. “On a grander level, hospitals could bring new technology to bear sooner-especially in the California market where standard construction requires a lengthy Office of Statewide Health Planning and Development review-as well as create a ‘hand-me-down’ equipment market for less privileged areas,” projects Scott Dunlap, architect and member of SmithGroup's health studio, Washington, DC.

Customization

Fundamentally, Johnson explains that modular buildings are pre-engineered at a basic level, and then customized per application.

For those manufacturers who specialize in medical units, such as Williams Scotsman, blueprints, developed over time, are used for a basic outpatient facility design, and then tweaked based upon facility needs. “For more complex designs, a customized architectural plan can be developed,” notes Cunningham.

Another medical specialist, MedBuild, emphasizes the industry-specific expertise offered by healthcare modular companies. “Because MedBuild is healthcare-focused and our staff is trained to understand the patient care environment, we take an applications approach to each project. This means that we work to understand the function of the facility from a clinical perspective, design a facility accordingly, and then use modular construction to accelerate the process,” explains Jim Gabriel, MedBuild's director of business development, Berwyn, Pennsylvania.

On the other hand, when too much customization is required, this begins to chip away at economies of sale, and ultimately, the cost to the end-user. “Customization challenges always come down to just how custom can you go before killing the advantages of mass production,” points out Rolf Haarstad, AIA, LEED AP, principal of the Baltimore-based architecture firm, Hord Coplan Macht.

“Newer technologies such as digital 3-D printing and computer-driven laser cutting allow a great degree of freedom, and certainly allow us as designers the chance to adapt a base model to different environments and site constraints,” he explains. “However, at what point is one simply designing a better, more technically advanced one-off design?”

Challenges

Of course, modular construction also comes with its set of challenges. Tying back to the issue of mass production, supply and demand can be an issue as modular units are still considered somewhat of a specialty product. Consequently, there is a learning curve which architects, engineers, and contractors must continue scaling before modular can achieve greater market penetration and better economies of sale.

This 5,578-square-foot dialysis facility in lagrange, kentucky, was built in just over two months by medbuild
Photo Courtesy of ModSpace

This 5,578-square-foot dialysis facility in LaGrange, Kentucky, was built in just over two months by MedBuild

Harstaad also sees modular facilities as suffering from an image problem. “They are generally considered low quality, cheap ‘trailers.’ As designers, we face the challenge of providing our clients with the same high level of design they expect from a traditional approach.”

Furthermore, during these tough economic times, many are less willing to go with such nontraditional alternatives, he claims.

Another issue is bring modular providers on board a little too late in the game, thereby compromising potential benefits. “The real challenge is getting involved in initial planning discussions as we can do even more to incorporate architectural energy efficiency, green building, and sustainability features when we work with our clients as a partner in the beginning phase of project design,” notes Gabriel.

From a technological standpoint, says Sheerin, the mechanical and electrical infrastructure must be fine tuned to seamlessly hook into the hospital system, whether it's making sure that the electrical panels are at the correct voltage, for example, or that the air handler is sized for the hospital's chilled and heated water temperatures.

Similarly, Jeff Cleary, project superintendent, KHS&S Contractors, Anaheim, California, agrees that it takes much skill and planning to accurately incorporate all the critical M/E/P and medical gas systems into the final product. “This is made even more challenging when working within constraints of available space.”

In addition, Sheerin points out that for stand-alone modulars, they also require their own fire alarm devices, fire sprinklers, paging, phone and data drops-“Just a host of things that need to be envisioned,” he says.

And on a more practical level, Johnson points to the challenge of meeting various code requirements, which will change from project to project and state to state.

Yet another tricky point is the fact that the pre-built modular units must be transported by truck to the jobsite. “Modular assemblies must be designed and built with dimensional parameters for shipment, so there is an added risk for damage and wear. Builders must make a conscious effort to protect finishes, plan for tolerances in the field, and pay close attention to any LEED certification requirements that might be affected by delivery,” adds Tracy Douglas, manager, Autodesk's AEC construction division, Atlanta, and Michael Cannistraro, PE, LEED AP, vice-president of engineering for the Watertown, Massachusetts-based M/E firm, J.C. Cannistraro, LLC.

Crystal ball

In terms of where the industry is headed with modular construction, the jury is still out. On the one hand, modulars can be a helpful stop-gap measure for meeting space needs without costly renovations and less disruption to the site.

A prefabricated and assembled modular digital mammography center and on-call physician suite was craned up and over cambridge hospital's existing structure in one day, causing no disruption to hospital operations
Photo courtesy of Triumph Modular

A prefabricated and assembled modular digital mammography center and on-call physician suite was craned up and over Cambridge Hospital's existing structure in one day, causing no disruption to hospital operations

Developed by hord coplan macht, william scotsman, and protech builders, this modular mri suite prototype manages safety concerns with clearly delineated zones while facilitating patient and staff flow
Photo courtesy of Hord Coplan Macht

Developed by Hord Coplan Macht, William Scotsman, and Protech Builders, this modular MRI suite prototype manages safety concerns with clearly delineated zones while facilitating patient and staff flow

But on the other hand, Harstaad claims, “Modular construction is not, by and of itself, less expensive than traditional delivery. It could, in fact, be slightly more expensive on a per square foot basis depending upon application.”

Where those savings generally come in is speed to market and easy replacement for future needs. But this requires getting the owner past first costs, which can be more challenging during a down market, claims Harstaad.

At the same time, others are much more optimistic, like Wagman and Sroke. “We see this trend continuing based on the value proposition and flexibility that modular construction offers. This is especially true in today's economic climate where organizations may be hesitant to undertake large-scale construction projects, yet need to add valuable services to their portfolio.”

Similarly, Gabriel points out, “The need for hospitals and other healthcare providers to generate more revenue by increasing patient cases and throughput will remain consistent. Pent up demand, healthcare reform, and reductions in reimbursements will only accentuate the need for cost-effective building solutions [like modular].” HD

Drop-In Modular for Cambridge Hospital

One great example of the flexibility leveraged by modular construction was the recent addition of a digital mammography center and on-call hospital physician's suite for Massachusetts' Cambridge Hospital. Following the off-site fabrication and assembly of 14 customized modules, the final 4,300-square-foot product was skillfully craned over the existing four-story and six-story hospital buildings with approximately six inches to spare on all sides, in just one day.

What's more, the entire installation created no disruption to ongoing hospital operations.

Adding an aesthetic touch, trellis grating was incorporated into portions of the exterior cladding to encourage the growth of ivy and vines, ultimately providing a green, garden-like view. In addition, interiors were well coordinated with the main hospital design.

“When you're walking through the hospital and you open the door to the mammogram lab, you wouldn't know that you're in a modular building,” observes Cliff Cort, president of the Littleton, Massachusetts-based Triumph Modular, whose company fabricated and installed the unit.

Barbara Horwitz-Bennett is a frequent contributor to publications and organizations dealing with building and construction. She can be reached at

http://www.bhbennett.com or

bbennett@bezeqint.net. Healthcare Design 2009 December;9(12):32-37