This article was originally published on Jan. 6, 2014, and is among Healthcare Design's Top 10 most-read articles of 2014. To see a full list, click here

When it comes to capital improvement projects, healthcare providers across the board are looking to reduce costs and shorten construction schedules while still seeking high-quality design and building materials. While this may seem like a lofty aspiration, modular building systems are stepping in to make it a reality.

Even just a decade ago, modular construction was seldom used in healthcare but today is picking up steam, with hospital owners turning to prefabrication for headwalls, bathrooms, or even an entire hospital. In fact, healthcare is currently the leading market sector utilizing modular construction at 49 percent, according to recent industry statistics. Furthermore, as healthcare organizations move toward more standardized environments and systematic approaches to care delivery, modular is proving to be a great fit.

For example, take the Miami Valley Hospital Heart and Orthopedic Center’s bed tower, which opened in 2010. As the first U.S. hospital to extensively apply modular prefabrication, the Dayton, Ohio, hospital’s patient rooms, exam rooms, single-toilet rooms, and patient-unit overhead utilities were all built at assembly warehouses just miles from the site and then erected on-site. The modular units worked exceptionally well with the hospital’s repetitive design, which incorporates 178 identical rooms on five identical floors.

“This degree of standardization provides flexibility, allowing functions to shift from floor to floor and reducing the need for patient transfers,” explains Ryan Hullinger, principal at NBBJ (Columbus), which designed the project. “The inpatient room dimensions, infrastructure, and environmental attributes are designed to support the broadest possible range of patient types and clinical activities, making each room capable of flexing from low-acuity use for general med/surg functions to maximum-acuity use for cardiac ICU.” The standardized components include identical room layouts so staff can quickly locate supplies and equipment, as well.

Another example is the four-story, 188,000-square-foot Texas Health Harris Methodist Hospital in Fort Worth, Texas, where instead of coordinating and installing on-site the dozens of electrical outlets and medical gas and vacuum lines required for each of its headwalls, the hospital opted to have all of the headwalls prefabricated off-site. “The efficiency gained is astounding compared to building headwalls in place in the building, where each trade is getting in each other’s way,” says Winjie Tang Miao, president, Texas Health Harris Methodist Hospital Alliance.

In addition, Texas Health used modular components for the patient room bathrooms and portions of the HVAC and plumbing systems. “We expected less material waste and decreased total labor costs but were pleasantly surprised when the actual savings exceeded our expectations. In some cases, we had more than 40 percent savings in materials and 30 percent improvement in labor,” Miao says.

Explaining how these cases of massive savings work, Hullinger says that off-site fabrication is a great way to bypass the intricate, painstaking process of organizing all the on-site routing and installation of complex building systems. “Regardless of the degree of coordination prior to construction, when highly complex architectural and engineering systems are conventionally installed in the field, the organization is often lost, wasting time and material,” he says. "This isn’t the case with our prefabricated approach, in which a coordinated layering of engineering systems is resolved digitally in BIM. The precise relationship between the BIM model and the fabricated components provides the building owner with a high-fidelity understanding of what’s inside the walls and ceilings, which streamlines future modification.”

In fact, savvy designers are even building future flexibility right into their modular designs, as was the case with the overhead MEP racks for Miami Valley, where linear “no fly zones” were left open inside each rack in order to accommodate future routing systems and provide easy access for maintenance.

Learning the ropes
Overall, NBBJ walked away with a number of lessons from the Miami Valley project. For one thing, the factory fabrication work proceeded along at such a clip that a second fabrication site had to be leased, since the contractors weren’t ready to install the units in the field.

Applying this insight to its next modular project, a new OhioHealth Riverside Methodist Hospital Neuroscience Institute patient tower in Columbus (scheduled to open in 2015), NBBJ was better able to manage the project timeframe to avoid monopolizing the fabrication shop as a storage area. In addition to incorporating the same modular systems used for Miami Valley, the scope of prefabricated components was greatly expanded for OhioHealth to include exam rooms, perioperative spaces, holding bays, and toilet rooms.

“There’s a long list of complex, multisystem components throughout the 410,000-square-foot tower being prefabricated, such as inpatient headwalls and the above-ceiling engineering racks in the inpatient wings and ORs,” says Tim Fishking, principal, NBBJ.

Future potential
While modular construction touts an impressive list of benefits, there’s still a certain stigma the method is struggling to overcome. “Historically, there have been some unfortunate associations with prefabricated architecture that was executed in a low-quality manner,” Hullinger says. However, this is far from what’s being produced today. Hullinger says that by standardizing components, designers and builders actually exert more control over the process, ensuring adherence to the design vision and creating greater aesthetic value.

Despite some design limitations (for example, required column work often doesn’t allow for open spaces like atriums), the ability to finish these structures with just about any exterior—be it brick, stone, stucco, or glass—means today’s modular buildings can look just like conventional architecture.

And as more modular healthcare projects are deployed, experts believe lingering doubts about the method will dissipate. Aspen Street Architects, Angels Camp, Calif., designed the Mercy Joplin replacement hospital in Joplin, Mo., relying heavily on modular construction. Founder David Hitchcock foresees a day when designing a freestanding clinic, hospital wing, or a critical access hospital will be similar to picking out a car, with all the features and amenities chosen by the end user. “I do believe that the field for modular healthcare construction is wide open at this time. There are just too many projects that could benefit from modular construction to believe that the concept could stagnate at this point,” he says.

 

Sidebar: Piece by piece at Parkland
While the nation’s largest public healthcare project to be built in one phase can use modular only to a certain exte
nt, the construction management team for Parkland Health and Hospital System’s 2-million square-foot Dallas hospital regrets not incorporating more modular components. “If you do have a project that’s conducive to a lot of repetition, don’t be too conservative about how much modular can be used,” says Walter Jones, senior vice president, facilities planning and development, Parkland Health and Hospital System.

For the $1.27 billion project tracking LEED Silver and scheduled to open in summer 2014, 862 bathroom pods were built by a contractor in a nearby warehouse and then transported to the site, as opposed to going with a modular company and a remote factory location. Whereas producing all these units in the field would have created some slight variation in the dimensions, by building the pods with a single workforce in an assembly plant, the consistency of construction is much higher. “Because I know exactly how each one was produced, this will be a great aid from a maintenance standpoint, as I have the exact template,” Jones says.

Beyond the bathrooms, Parkland is using modular components for the adult patient room framework, headwalls, and rough-ins for the outlets and lines. For the patient tower, the main MEP ductwork, plumbing, fire protection, and cable trays were built in 20-foot-by-20-foot sections, raised up to the ceiling, and connected together.

“My construction manager is cautiously reluctant to put metrics on the benefits from a cost or scheduling standpoint, but quality-wise, it’s already clear that we’ve gained a big advantage from the modular construction,” Jones says.

 

Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at bbennett@beqeqint.net.