Building the role of the clinical property adviser in a new healthcare setting
Instead of buying in the services of a healthcare planner, NHS Grampian developed the role of an in-house clinical property adviser to help build the new Royal Aberdeen Children's Hospital.
Transforming a building site into a fit-for-purpose healthcare facility is a complex process involving a range of people, each with different skills and experience, as well as effective team working.
Many NHS organisations buy in the services of a healthcare planner, who has expertise in service redesign, business-case development, change management, project management and compiling post-project evaluation reports, at high cost.
However, NHS Grampian developed the role of clinical property adviser (CPA) to take over some aspects of the planning and development of new healthcare facilities. I was appointed to this role in 2005 after being part of the project team for the building of the new Royal Aberdeen Children’s Hospital (RACH), which started in 2000. Before this, I was a sister at the old RACH, and had worked in hospitals in London and Kent after my initial nurse training in Glasgow.
Training and preparation
To fulfil this role, I had to develop a new set of skills. These included understanding architectural plans and technical specifications, and translating this information to colleagues, and interpreting medical and clinical specifications for the design team, to ensure the facility was fit for purpose.
Most of these skills have been self-taught, with the support of experienced technical project managers, although I took training courses for the additional computer skills I required. I also undertook a master’s degree in management studies, which helped with the change management aspects of the project. At the end of the RACH building project, the CPA role was confirmed as a permanent post. It was agreed that having an experienced clinician as part of a building project team can help to ensure that new or refurbished buildings will meet service needs, and staff and patient expectations.
Building projects, such as the RACH can be divided into five stages: planning, staff and patient involvement, construction, commissioning and occupation, and post-project evaluation, and the CPA plays a vital role in each.
The wider project team, which includes members of the hospital management team and clinical staff, identifies service needs, objectives and benefits, and these determine the accommodation required in terms of room types, size and quantity. Workshops are arranged for the project team to establish clinical functionality, to allow for example for patient flow and to establish optimum layout, and some of these workshops are open to the public, patients and staff representatives for feedback.
Each stage of the HAI-Scribe is signed off by:
- The project team.
- NHS personnel including infection control and estates teams.
- The design team.
- The construction company.
Plans for the whole building, floor by floor, are drawn up by the architects and engineers, and show the position of equipment and fitments. Room data sheets, which are documents with different sections relating to function, environment, design and schedule of equipment, are developed by the CPA and agreed with staff representatives for each area.
The CPA also takes the lead in undertaking a Healthcare Associated Infection System for Controlling Risk in the Built Environment (HAI-Scribe) assessment, in accordance with a guidance document, issued by the Scottish Government, that examines proposed sites for risk of contamination, identifies protective measures that may be required by contractors during the construction process and describes specifications for flooring, sinks and taps, and wall and ceiling finishes.
The CPA reviews the architectural plans, and requests any necessary amendments before sharing them with staff representatives. It is vital that they are consulted, and sign off the plans, and the CPA supports this process. Care must be taken to ensure good clinical functionality of the new facility, but also to manage expectations, as staff do not always appreciate there are likely to be limitations to the design due to space or finances.
A member of staff from each area, referred to as a ‘briefer’, and normally a senior nurse, is nominated to take responsibility for signing off the plans because, although the CPA has a clinical background, briefers have in-depth knowledge of the resources required, the likely demands on the service, and how these can be managed in the space and finance available.
Staff and patient involvement
This stage involves infection control measures, equipment lists for purchase or transfer to the new facility, progress reports and feedback, public open days and newsletters, as well as policy and protocol development. It is important to involve staff from areas, such as infection prevention and control, health and safety, information technology and communications, that are relevant to the project and for them to become part of the wider project team and to be invited to meetings as required.
Discussions about equipment lists can be difficult, as staff expectations must be managed according to the project budget, but at the same time the new facility must be appropriately equipped to meet service needs.
Progress reports and feedback are important to ensure staff feel involved in the project, and to help them develop a sense of ownership of the new facility. Public information and involvement are also important, especially about how the project is likely to affect local services or the environment; most construction companies, for example, distribute regular newsletters to site ‘neighbours’ to keep them informed of progress and to warn of possible disruptions or excessive noise.
Policies and protocols may need to be developed, or existing ones adapted, for the new facility. This is another area in which an experienced CPA is invaluable, because they are better equipped than most to envisage how polices will apply to a new facility.
This stage includes site visits, technical and progress meetings, positioning of equipment and compliance with NHS standards, relating for example to room size, fire safety regulations and bed spacing. This is when the CPA dons their hard hat, high-visibility jacket, and safety boots, and goes on site to ensure the building is progressing in line with design, and to the approved standards. Attendance at technical and progress meetings ensures that the CPA is aware of any proposed changes to specifications, and can respond to queries.
Correct positioning of equipment is vital to ensure that the rooms are fit for purpose. Although positions may be indicated on the architectural plans, the end result may not be as foreseen, so the CPA checks positioning to ensure each area will be functional.
The project team works together to ensure that the building complies with NHS building standards, health and safety regulations and infection control requirements. Site visits are made regularly, and any ‘snagging’ issues are recorded and given to the construction company to address.
Commissioning and occupation
This stage involves delivery and installation of equipment, cleaning, staff orientation, open days for staff and the public, staff relocation and transfer of services. Before this though, the equipment lists are updated, and the project team meets with staff to check these are correct and meet expectations. Sometimes staff expect almost everything to be new, while at other times they are so used to the equipment they cannot see it is no longer fit for purpose. Equipment for transfer is usually marked so that the removal company can identify what to take, and staff are encouraged to remove unused materials so they are not transferred only to be discarded later. Dates for the delivery of new equipment are agreed, and teams are established for installing these in the new facility.
As part of the HAI-Scribe, the construction company is committed to cleaning the building after completion, and before it is handed over to the NHS. This is followed by thorough cleaning by NHS staff to ensure it meets the required standards. This process is complicated by all the other activities, such as delivery and positioning of equipment and staff orientation visits, going on at the same time so floor protection is usually laid to reduce the risk of damage and the need for more cleaning.
It is important to orient staff to the new facility, but it can be challenging to release them from their duties in their existing workplace. One way of managing this is for the project team to show some staff round and then ask them to do the same for their colleagues at another point. Hosting open days for staff, patients and the public can also help manage the transfer of services more effectively, and ensure that people know where services are located.
'The relocation process usually involves a partial reduction of services, and those affected must be informed about this, and given clear timescales. Moving day requires everyone to work as a team to ensure the new facility is up and running as soon as possible'
The post-project evaluation is a mandatory requirement by the Scottish Government for all NHS new and refurbished projects, as laid out in the Scottish Capital Investment Manual (2010), and should be undertaken around a year after occupation of the new building. One of the main challenges of this timescale is that sometimes the clinical staff, design and construction teams involved in the project have moved on, and it can be difficult to locate them for feedback. To take account of this problem, requirements are being amended so that evaluation is a continuous process throughout a project.
Evaluation requires specific knowledge, skills and experience, and again some NHS organisations procure outside staff. However, as NHS Grampian’s CPA, I have the research and report-writing qualifications required to carry out evaluations, and those I have undertaken have been audited externally and found to comply with all the requirements. A summary of the evaluation document is shown in Box 1.
Box 1. Post-project evaluation document
The main document comprises four parts, each containing several sections, in addition to a post-occupation questionnaire that does not always form part of the main report.
Part 1: Key project data. This gives a brief description of the project and the details of all parties, NHS and external, who are involved in the project.
Part 2: Detailed evaluation. This is the main body of the report, and covers all aspects of the project including:
- Project brief and description.
- Strategic review, with defined aims and objectives, as well as benefits-realisation outcomes, which measure improvements in specific areas against baseline figures recorded at the start of a project.
- Cost analysis.
- Time analysis.
- Performance of project participants, assessed by distributing questionnaires to participants, including the NHS Grampian project team, the design team, external advisers and the construction company. They are asked to assess specific aspects of the project, what they think went well and what did not, and to dentify lessons that can be learned. They are also asked to score the performance of members of the whole project team.
- Health and safety performance.
- Techniques adopted to manage the project effectively; these could include meeting arrangements, for example, or the electronic systems for storing and sharing documents.
- Assessment of the final product, in terms of quality, and variations in timetable and costs.
- Lessons learned. This is the main function of the report, and the NHS board shares the information with staff involved in the project. When the report has been submitted to the Scottish Government, the lessons learned are recorded and shared between all Scottish health boards.
Part 3: Client satisfaction. This is a combined assessment by the NHS Grampian project team and the staff who use the building, and relates to quality of finish, meeting service needs and delivery within time and cost estimates.
Part 4: Project overview. This gives the project director, finance team and in-house clinical professional adviser the chance to assess the report and comment.
Part 5: Post-occupation survey. This is not always part of the main report, but is usually completed at the same time and included in the final report.
Questionnaires are issued to a random selection of members of the project team, briefers and staff working in, and patients using, the new building. The questionnaires vary slightly for each group, but briefers and other staff are asked how they perceive the project has been managed, if they were adequately consulted and updated, how well the building functions in relation to their service and how they feel about the design. Patient questionnaires are less detailed, but include questions about access to the building, ease of use, noise levels, design and ambiance.
Table 1 lists some of the issues identified in different projects undertaken at NHS Grampian, and the action taken.
Benefits of an in-house CPA
The benefits of the CPA service are that the post-holder has knowledge of the local area, its service requirements and service provision, the experience required to challenge existing practice and to encourage new ways of working, and credibility because of their clinical background. The CPA service is also cost effective, as NHS organisations do not have to employ external consultants. CPAs can also build relationships with the various teams involved, and are on hand to respond to issues and concerns. At NHS Grampian, the post is now well established, so this eliminates the ‘learning’ time required at the start of new projects.
Table 1. Lessons learned and action taken
|Document issue and control. Sharing amended plans was not well managed||Implementation of an effective document-management system|
|Lack of effective team working||Team-building workshops undertaken at the onset of the project|
|Post-occupation assessment review highlighted issues about the distribution and return of staff questionnaires||A new system, where the evaluation team, not the managers in the new or refurbished facility, would issue questionnaires to a random selection of staff from a list, and reassure them about the confidentiality of their responses, was agreed|
|Pressure to complete the commissioning of the new facility unreasonably quickly or under other difficult conditions||Commissioning, and relocation of services, to take account of likely periods of extreme weather. Adequate time and resources for the commissioning process and ensure appropriate orientation allowed|
|Defining roles||Specific role requirements, including a commitment to attend relevant meetings, agreed by all main stakeholders at the outset of the project|
|Staff in specialist areas felt they had not been involved enough in finalising specifications||Specification for specialist areas now agreed by the staff working in them, not just signed off by their managers|
|Staff should be given a clear idea of the dimensions of the new facility, compared to the old one||Information provided to staff to give them a better understanding of the process, the outcomes and how they can influence these outcomes. Staff given a clear idea of the dimensions of their new facility, and how this compared to the old one. More staff and user engagement was maintained throughout the project|
To access the Scottish Capital Investment Manual, go to Scottish Government (2017) Scottish Capital Investment Manual
Elizabeth Norris is clinical property adviser, property and asset development at NHS Grampian, Aberdeen, Scotland