canadian health care

Canadian Health Care Facilities (CSA Z8000-11)

The NEW Standard for Design and Construction of Canadian Hospitals & Health Care Facility

Canadian Health Care Facilities (CSA Z8000-11)Cliff Harvey OAA, MRAIC, Senior Architect,

Ontario Ministry of Health and Long-Term CareCSA healthcare facility technical committee

Michael Keen PEng, MBA, Projects Planning Director, St. Michael’s HospitalChair, CSA healthcare facility technical committee

Robin Snell Architect, OAA, AAA, MRAIC, LEED AP, Principal, Parkin Architects LimitedCSA healthcare facility technical committee

November 15, 2011E33 HCD 2011, Nashville

AGENDAOverview of the Canadian Healthcare System

hospital fundingcapital planning (building) process

What is CSA Standard Z8000-11?creating a standardcodes, standards, guidelinesgoals, objectives, overview

Z8000-11 Features & Contentkey featuressample details & hot topicscomparison with other standards

How will Z8000-11 be Implemented?


Overview of the Canadian Healthcare Systemhospital fundingcapital planning (building) process


Most important Canadian (based on 2004 CBC documentary)

a) Tommy Douglas b) Wayne Gretzky(1) (10)founder of universal healthcare 1966 ‘the great one’ - hockey player

10 X


Source:http://www40.statcan.gc.ca/l01/cst01/demo31a-eng.htm

Canada: Population

Federal: Health Canada

Sourcehttp://www.hc-sc.gc.ca/hcs-sss/index-eng.php

Provincial Systems


6 HA

5 Z

13 HR1 HA

11 RHA

14 LHIN

18 HR

2 HN9 DHA

4 HA

1 HA

1 HA1 HA

1 HA

LegendHA Health AuthorityZ ZoneHR Health RegionsRHA Regional Health AuthorityLHIN Local Health Integration NetworkHN Health NetworkDHA District Health Authority

Canada: Health Authorities

10 Provinces + 3 Territories*

• 86 different health region

• +/- 874 Hospitals / Health Centre

Quebec*

• 21% of the population

• 10 % of Canadian Hospital

Ontario*


• 25% of Canadian Hospital

Remaining 8 Provinces + 3 Territories


• 65% of Canadian Hospitals* Preliminary study numbers subject to verification

Canada: Hospitals


PROVINCE OF ONTARIO, CANADA

Province of Ontario, Canada

Province’s Population:13.2 million

Province’s Area:1.07 million sq km (415,589 sq mi)

Province’s Density:3.8 /Km2 (36 / mi2)

Toronto’s Population: 2.5 million

Toronto’s Metropolitan Population: 5.5 million


Human resources• Physicians: 24,875* (2010)• Registered Nurses: 115,285* (2011)• Registered Practical Nurses: 39,485* (2011)• Nurse Practitioners: 1,932* (2011)• Pharmacists: 11,833* (2010)

•In total over 350,000** people work in our healthcare system (2005, regulated and unregulated)

• * Data from public internet sources (regulator’s sites)• ** http://www.health.gov.on.ca/english/public/pub/ministry_reports/hhr_05/hhr_05.pdf

http://www.health.gov.on.ca/english/public/pub/ministry_reports/hhr_05/hhr_05.pdf�

Ontario health infrastructure*• 226 Hospitals (150 Corporations) (+/- 30,000 beds)• 634 Long Term Homes (LTC) (+/- 76,000 beds)• 969 Independent Health Facilities (IHF)• 55 Community Health Centres (CHC)• 334 Mental Health Programs• 150 Addiction Programs• 6,900 Supportive Housing Units• 3,600 Homelessness Supportive Housing Units• 3,400 Pharmacies

• Budget (estimates 2011)*• $ 47 billion (Overall)• $ 22 billion (LHIN)• $ 17 billion (OHIP)• $ 4.9 billion (Provincial Programs)• $ 1.4 billion (Capital)

• * Data from public internet sources • ** http://www.fin.gov.on.ca/en/budget/estimates/2011-12/volume1/MOHLTC.html

http://www.fin.gov.on.ca/en/budget/estimates/2011-12/volume1/MOHLTC.html�

Capital Planning Process

http://www.health.gov.on.ca/en/news/release/2011/jul/fs_20110728_1.pdf



What is CSA Standard Z8000-11?standards overviewcodes, standards, guidelinesgoals & objectives

Context for a new standard - Why now?

• Capital spending on HCF• No Canadian standard• Evidence based design• Shortage of planning/design skills• Public awareness of safety• Pandemic fears• Increasing technology integration• HCF definition blurring


Health Care Facility Design Standards

“The Blue Book”


CSA


• CSA international reputation personal safety• 40 years standards development• 200 existing component standards in healthcare• Reputation of integrity, technical credibility,

transparency in process• Balanced matrix committee, consensus process• Inclusive participation, respect for diverse

interests, multi disciplinary representation• Written in code language – can be adopted

26November 15, 2011E33 HCD 2011, Nashville

CSA Health Care Facility Standards

• Electrical• Medical Gases• Plumbing• HVAC• Illumination• Infection Control• Area Measurement• Commissioning• Sterilization• Medical devices


Standards Development Process

• Request/Evaluation/Approval• Establish Committee• Draft Development• Public Review• Internal Quality Audit• Balloting• Translation• Publication


Standards Maintenance Process

• Ongoing Monitoring• 5 year review• Committee recall as needed• Revisions• Amendments/New Edition• Withdrawal


Overview of Standards

• Standards in general– Information documents– Stipulate requirements for the safety,

performance and operation of products, processes, services and systems

– Represent minimum requirements– Are voluntary; compliance becomes mandatory

only when the standards are referenced in legislation or regulation


CSA Z8000 - Health Care Facilities

• First comprehensive National Standard for HCF• 33 members, 4 year development, 400 pages• New construction AND significant renovation• “Shalls”, “Shoulds” and Best-Practice guidance• Objective and performance based• Not a specification or a replacement for design

innovation• Functional Approach• Reference existing CSA standards, not re-write

them


Who Writes the Standard?

• Architects (RAIC rep) 5• Functional Planners 2• Mechanical Engineers 3• Electrical/IT Engineers 2• Health Canada 1• Doctors/Clinicians 3• Facilities Management 2• Hospital Planners 2• Controls Contractor 1

• Nursing 3• Prov. Health Ministries 6

(AB, NF, ON, PQ, NB, BC, MB)• Infection Prevention & 3

Control Practitioners (CHICA)• CHES Rep 2• Occupational Health & 2

Safety• Hospital Administration 2

(30-35 People)


Development of the Standard

• June 2003 - TC Meeting Concept Discussion• 2005 – Business Case• 2006 – Approval to form Technical Subcommittee • March 2007 – First Subcommittee Meeting• April to June 2010 -

Public Review• June 2011 – Committee Vote • September 2011 – Publication


Sections of the Z8000 Standard

• 1-3 Scope, References and Definitions• 4 Principles• 5 Planning• 6 Site and Facility Development• 7 General Functional Requirements• 8-10 Specific Requirements• 11 Common Technical Requirements• 12 Building Services


Section 4 – General

Principles of Health Care FacilitiesOperationsAccessibilitySafety and SecurityInfection Prevention

and ControlSustainability


Healing Environment?


OASIS - OPERATIONS• Environment of Care for the Patient

– Promotes Healing, Wellness

– Sensitive to Needs ofIndividuals

• Clinical Functionality– Effective Delivery of Care

– Effective Application ofEquipment

– Efficiency of Operations

• Support Services to facilitate the Environment of Care and Clinical Functionality


OASIS – ACCESSIBILITY

• Minimize barriers, consideration of disabilities

• Effective and appropriate wayfinding• Minimize patient travel• Staff workflow• Provision of supplies• Wait times• Provision for family support• Patient and patient information

communication


OASIS – SAFETY & SECURITY

• Errors in delivery of care• Environmental hazards• Equipment hazards• Criminal activity• Privacy and dignity• Emergency conditions


OASIS – INFECTION PREVENTION/CONTROL

• Preventing transmission of pathogens between people

• Preventing the creation and propagation of environmental irritants

• Waste management• Application and handling of

supplies, instruments and equipment

• Caregiver and patient hygiene


Semi-Privates – Obsolete?


OASIS - SUSTAINABILITY

• Promote patient, staff and occupant wellness• Socially responsible impact on the environment

(Green)• Flexibility to accommodate future change• Appropriate for needs of the community and

patient population• Total cost of operation


Section 5 – Planning Process

• Master Program• Master Plan• Functional Program• Design• Procurement• Construction• Commissioning• Occupancy• Evaluation


Section 6 - Site and Facility Development

• Site requirements

• Facility requirements– Form and function

– Wayfinding

– Expansion

• Key relationships and dependencies


Section 7 - General Functional Service Requirements

7.1 Planning7.2 Materials and Finishes7.3 Furniture, Fittings and Equipment7.4 Technology and Communications7.5 Infection Prevention & Control7.6 Occupational Health & Safety7.7 Safety and Security7.8 Accessibility7.9 Catastrophic Event Management7.10 Flexibility & Adaptability


Section 8 – InpatientSection 9 – Diagnostic and Treatment Section 10 – Support ServicesSection 11 – Common Requirements• Table of 51 room types or spaces that occur

across different areas

Functional Service Requirements


Section 12 – Building Services and Environmental Design

• Site Systems• Architectural• Structural• Mechanical• Electrical• Information Technology• Security Systems



Overview of Z8000-11 Contentkey featuressample details & hot topicscomparison with other standards

Z8000-11 Key Features

does NOT include HCF operations


Facility Types• Acute Care Hospital• Academic Centre• Rehab Facility• Urgent Care Centres• Ambulatory Care Centres• Long Term Care• Surgi-centres• Shopping Mall Clinics (eg Endoscopy)• Doctors and Dentists Offices• Home Care and Mobile Services



Renovation vs. New Construction• General intent – renovation to meet the standard• Could be difficult to achieve in new construction• Difficult in renovation projects??



“Call the doctor, I have acronymosis”

EBD LEED LEANBPE P&FCC H&WBIM IDP P3, AFPDB, CM BF/UA/BARI QofCROI IT ATT/RETVE POA EBTKSBEN OASIS

implementation of current best practice


Component gross square metres (CGSM) –that portion of a building assigned to a specific component, including net areas, internal circulation, partitions, building structure, and small mechanical shafts.

Note: CGSM includes all individual net areas required by the departmental functions, circulation space necessary to link together the net spaces and area occupied by internal walls. It excludes all engineering spaces and interdepartmental circulation elements such as main corridors, stairways, elevators and dumbwaiters


Class C HCF — an HCF in which ambulatory patients a) are accommodated on the basis of medical need; b) are provided with non-invasive medical services for

diagnosis, treatment, or therapy; andc) and stay for no more than 12 hours (except for residential

facilities in which occasional care is provided.)Notes: Class C facilities include those facilities where patients remain capable of self preservation.

Class C HCFs include outpatient clinics, dentists’ offices, doctors’ clinics, and privately run residences.


Common Language (en anglais et français)

• Working in multiple jurisdictions• Various HCF project types & scale• Multi-disciplinary ‘peer sharing’• Common terminology amongst a diverse group of

HCF practitioners and design professionals

Quiz a) seclusion room b) secure room

c) psychiatric IC room d) secure observation room



Common Language d) secure observation room

Seclusion Room


Key Relationships and Dependencies

• Related Programs• Components within the program impacting the

relationship• Objectives• Alternatives to direct adjacency of programs



Key Relationships and Dependencies Matrix

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Critical careMaternal & newborn careMedical/surgical inpatient careMental health carePediatric & adolescent inpatient careRehabilitation careSpecialized inpatient careAmbulatory care - generalAmbulatory care - renal dialysisAmbulatory care - oncologyEmergency careProceduresAllied health servicesLaboratory servicesElectrodiagnostic servicesRespiratory servicesMedical imagingPharmacyBiomedical engineeringEnvironmental servicesNutrition and food servicesMaterials managementPlant maintenanceSecurity & parkingMedical device reprocessingBuilding entry & parkingHeliportExterior garden/therapy areaMain hospital entry/lobbyInpatient Continuing Care

LEGEND

Critical Relationships that are critical to patient safety and clinical peformance

Important Relationships which are important, but of normal base-level importance to patient safety and clinical performance

Key Relationships and Dependencies



August 25, 2009Test Presentation

“Higher probability of a workable solution”Steve Bagworth – Z8000 committee member, architect & functional programmer

Mandatory(a) to (u)the ‘shalls’

Z8000-11 Sample Details

Plus advisory(a) to (h)Plus advisory

(a) to (h)the ‘shoulds’


“Higher probability of a workable solution”Steve Bagworth – Z8000 committee member, architect & functional programmer


macro to micro – hand wash sinks

Z8000-11 Sample DetailsZ8000


(a) to (l)

macro to micro – hand wash sinks

Z8000-11 Sample DetailsZ8000


2 pages of HHSshall’s & should’s

Z8000macro to micro – hand wash sinks


Consensus General to Specific

Example Sound levels in an NICU

Provide a ‘quiet’ environment for the NICU including;

- higher STC ratings for partitions - higher NRC & CAC ratings (ceilings)

- lower NC ratings (background noise)



Consensus General to Specific

Example Sound levels in an NICU (infant room)

STC 55 (45) NRC 0.75 (0.95)

CAC n/a (26) NC n/a (25 ??)

a US standard for Newborn NICU Design – Feb. 2007

“a number to hang your hat on”



Consensus Minimum room sizing

Alberta Ontario Quebec Z8000-11Operating room, general 60.0

64658.6631

50.0538

55.0592

Level one recovery (isolation room), plus anteroom

25.0269

13.0139

N/A 18.0194

1-Bed Room Suite 31.0334

26.0280

23.5253

27.0291



Bed Clearances

Inpatient Beds * Critical Care Beds *

Non-transfer side of the bed 1000 mm 1200 mm

Foot of bed 1200 mm 1500 mm

Between beds (where there is more than one bed)

1200 mm 1800 mm

Centre to centre of beds (where there is more than one bed)

1800 mm 2400 mm

* Based on a nominal bed size of 1000 mm width or 1200 mm wide for bariatric beds



Non prescriptive

you still need to design & specify it



single bedded rooms

27.0 m2 (290 sf) net per single room (including a 3 pc washroom)

49.0 m2 (527 sf) net per double room (including two 3 pc washrooms)

Z8000-11 Hot Topics


100% single roomsLength 46.5 mArea 406.4 m2


- 2.1% *


- 4.2% ** Area difference doesnot represent CGSM

27 m2 49 m2

single bedded rooms

Z8000-11 Hot Topics

GOS Acute Care Accommodation Study

Direct Capital Cost Impacts (2)

•Estimates for Options (30%, 60%, 80%, 100% Private Beds)

30% Private 60% Private 80% Private 100% PrivateNet Area (NSF) 11,280 12,130 12,620 12,810 Departmental Gross Area 18,048 19,408 20,192 20,496 Bldg Gross Floor Area (GFA) 23,462 25,230 26,250 26,645 DGSF per Bed 564 607 631 641 Total Cost $ 11,064,087 $ 11,941,852 $ 12,461,485 $ 12,685,050 Cost per DGSF $ 613.04 $ 615.31 $ 617.15 $ 618.90 Cost per BGSF $ 471.57 $ 473.32 $ 474.72 $ 476.08 Cost per Bed $ 345,753 $ 373,183 $ 389,421 $ 396,408

$ 27,430 $ 43,669 $ 50,655 7.93% 12.63% 14.65%

Capital Cost over Baseline

* Based on 1 washroom per double bedded roomOctober 2007

Patient Lifts – should or shall?

Z8000-11 Hot Topics


Z8000-11 Hot Topics


Z8000-11 Hot Topics

patient lift capacity 200kg 441 lb

bariatric lift capacity 453kg 1000lb


Where can I store that?

Z8000-11 Hot Topics


storage no less than 2% of the total area of the service

Z8000-11 Hot Topics

Example – Typical Medical/Surgical Floor– 1500 m2 DGSM (16,146sf)

– Storage = 2% x 1500 m2

– Storage = 30 m2 (323 sf)

– Approx size of storage = 5.5 m x 5.5m (18’ x 18’)


To LEED® or not to LEED®

Z8000-11 Hot Topics


To LEED® or not to LEED®


Other Canadian Standards (partial list)• Ontario Ministry of Health and Long term Care: Generic Output

Specifications (2008)• Vancouver Coastal Health Design Guidelines: Complex Residential Care

Developments (2007)• Ontario Long-Term Care Design Manual (1999)• Quebec: Guide d’aménagement des centres d’hébergement et de soins de

longue durée (2002)• Alberta Infrastructure: Technical Design Requirements for Health Care Facilities

“The Blue Book”, 2005• Alberta Health Services: Design Standards and Guidelines for New

Construction or Rejuvenation of Long Term Care Centres and Designated Assisted Living Facilities (Draft 2009)

• Health and Welfare Canada Standards• Family-Centred Maternity and Newborn Care: Canadian Guidelines• Planning and Design Guidelines for New Brunswick Hospitals for Supply and

Services

Z8000-11 other standards


International Standards (partial list)

• Australasian Health Facility Guidelines, 2008• South Africa Hospital Norms (SAH Norms); National

Department of Health• Netherlands• UK’s National Health Service (NHS) • New South Wales (rebranded Australasian Health Facility

Guidelines)• Health Authority - Abu Dhabi (prepared in early 2011 similar to

Australasian Health Facility Guidelines)• Design Guidelines for Hospitals and Day Procedure Centres,

Victoria, Australia



American Standards (partial list)

• AIA/FGI, Guidelines for Design and Construction of Health Care Facilities, 2010

• Uniform Facilities Criteria – US Army Corps of Engineers• US Department of Veterans Affairs, Office of Construction &

Facilities Management – Design Manual• Environmental Standards Council; part of The Center for Health

Design• SpaceMed.com, Healthcare Facility Planning Tools and

Guidelines



Z8000-11, Canadian health care facilities, 2011

• First edition 2011 • Published editions 1• Pages 393• Room templates (plans) no• Includes healthcare operations no• 100% single care rooms yes (with exceptions)



AIA/FGI, Guidelines for Design and Construction of Health Care Facilities, 2010

• First edition 1947 1974 - 1st edition with public input 1984 - last edition published by federal government 1987 – 1st AIA edition

• Published editions +/-6?• Pages 411• Room templates (plans) no• Includes healthcare operations No (confirm)• 100% single care rooms yes (with exceptions)



AIA/FGI, Guidelines for Design and Construction of Health Care Facilities, 2010

Contents

1 General – ‘planning, design, construction, commissioning overview’2 Hospitals (p45 – 214)3 Ambulatory care facilities4 Residential Health Care Facilities5 Other Healthcare Facilities6 Ventilation of Health Facilities



Australasian Health Facility Guidelines, 2008

• First edition 2006 • Published editions 2• Pages +/- 1400• Room templates (plans) yes• Includes healthcare operations yes• 100% single care rooms ???



Australasian Health Facility Guidelines, 2008Contents

Part A IntroductionPart B General Requirements

Briefing & PlanningPart C Access Mobility OHS SecurityPart D Infection Prevention ControlPart E Building Services Environmental Design

Project ImplementationRoom Data SheetsRoom Layout SheetsSchedule AccommodationStandard Components



Minimum room sizing

FGI/AIAAusiHFG

CSAZ8000

Operating room, general 37.2400

42.0452

55.0592

Operating room, large 55.7600

52.0560

60.0646

Level 1 Recovery room 7.4380

9.097

9.0 to 13.097 to 140

1-Bed Room Suite ????

20.0215

27.0290



Z8000-11

Z 8000 Z 8000Z 8000

‘Leveling the raised bar’ (“leveling the playing field”, “raising the bar”)

• a planning & design resource• a practical tool for design decisions• a practical document for approvals




Will it be a Standard? Policy?Best Practice?

?

?

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??

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✔

✔



Alberta

• Alberta Infrastructure (AI) concerned about associated costs (e.g. single rooms)

• A Committee will be created to review the Standard and recommendations will be made to the Ministers on how this standard should be used in Alberta

• AI project managers and the industry is already using the document (even in its draft form)

• Alberta Health Service (AHS) encouraging ‘clinical liaisons’ to use the document as a reference

“The Blue Book”



Ontario

• A committee of the ministry’s architects and clinical specialists will review the contents of CSA Z8000 with Ontario’s Generic Output Specifications (GOS).

• MOHLTC is encouraging all project teams to refer to Z8000, especially were GOS maybe silent on a particular item, and to bring forth conflicts between the documents for discussion.

• The committee will bring forth its recommendation for implementation to senior management in Spring 2012.

Canadian Health Care Facilities (CSA Z8000-11)

Questions?

[email protected]@[email protected]

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