THINKING 2016

Integrated Systems
Testing of Healthcare
Facilities
Adrian Jenkins, Technical Director, Buildings, Aurecon
with
Susie Pearn, Global Expertise Leader, Health, Aurecon
THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Our thinking series

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THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES
Introduction
The role and complexity
of technology in health is
increasing. Healthcare,
technology and buildings are
becoming more and more
integrated. This promises better
efficiency and better health
outcomes but is also promises
increased risk. From Aurecon’s
30 years plus of designing and
managing hospital developments
we have built a rich database of
lessons learnt in building and
operational commissioning. It
is obvious from this that with
increased technology complexity
and integration, the risks
associated with commissioning
hospitals are increasing.
Gold Coast University Hospital
Commissioning is the turning point of a
project into a health service. It is where
it starts to become real. It is where
the ultimate users begin to take the
hospital into their own hands.
Failure in commissioning can have
a significant impact on the users,
including patients, clinicians, nursing
staff and hospital engineers. Patient
safety is always paramount and there
is the real potential for a poorly
commissioned hospital to put patient
safety at risk.
THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES
In the context of the unsustainable rise
in the cost of healthcare, we have the
responsibility to optimise the tuning
our hospitals. While building and
operating hospital infrastructure
typically contributes less than
10% of whole of life costs, a poorly
commissioned hospital can have a
negative impact on staff productivity,
where the majority of the cost of
healthcare lies.
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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

The challenge

The terms commissioning, total

building commissioning and integrated
systems testing (IST) are widely used
and commonly misunderstood. The
importance and benefits that these
processes bring to the seamless
handover of a healthcare facility are
frequently undervalued and often given
a lesser priority in the rush to meet the
project practical completion deadlines.
IST is one subset of these processes,
and when done comprehensively
can heavily de-risk the completion
process by addressing the potential
disconnection between designers and
trade contractors who may design,
test and commission their respective
systems in silos, resulting in the
overall facility operation and operation
Lady Cilento Children’s Hospital in normal failure modes not being
thoroughly proven.
A robust IST process provides a
“Even if a project is in all other aspects hugely successful, if holistic approach and methodology
via a regimented series of testing
commissioning goes awry, the long term repercussions can be that addresses a predefined series
significant and it can be seen to be a failure. The industry of operational and failure scenarios.
needs to learn from experience. The risks associated with Through this process the correct
commissioning need to be acknowledged and managed. In this operation of all systems can be
demonstrated individually and
paper we focus on just one aspect of managing this risk – integrated
collectively to provide a predicable
commissioning – and share what can and should be done right operational outcome.
now. We believe that the complexity of technology and integration Whilst IST is a widely acceptable
between health services, buildings and technology is only going to deliverable concept at the practical
increase. So what’s next? What could commissioning completion stage of a healthcare
look like in the future?” project, what constitutes a pass or a
fail criteria is rarely comprehensively
defined. It is also common for project
Susie Pearn, Global Expertise Leader, Health, Aurecon
professionals that provide final
assurances as to the completeness of
IST (and commissioning) to rely upon
third party statements attesting that
the installation is actually complete.

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

The challenge

Since the operation and interfaces are

not physically tangible assets that can
be sighted and accounted for readily,
there is a risk that a financier, quantity
surveyor or project manager may
provide premature acceptance of the
completed installation.
Carrying out IST in an unstructured,
ad-hoc manner manifests in the facility
experiencing unplanned downtime,
resulting in reputational, program,
material and financial loss or worst
still, adverse impacts on occupant
and patient safety and wellbeing from
incorrect operation of life safety,
electrical, electro-medical, security and
infection control systems.

Wagga Wagga Health Service (WWHS) Redevelopment Project

Kempsey District Hospital

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THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

What gets measured gets

managed

There remains a considerable

difference in opinion as to who is
responsible for IST and what the
process should comprise. There is also
very little guidance in the Australian
context around this type of testing.
For this reason there is a tendency to
rely on previous experiences and a
qualitative approach.
Thus it is common for bespoke tables,
tick-lists and schedules to be used on
projects. Also due to inconsistencies
and misconceptions around what is
actually required in the IST process in
Requests for Tenders and Professional
Services Agreements, wild fee and
cost fluctuations can be seen between
individual parties when seeking pricing
from designers, suppliers and trade
contractors alike.
Engaging lower cost alternatives can
lead to end user expectations not
being met and by taking this early
saving there is more risk of more time
and money being spent in the post
occupancy phase through revisiting
the IST process – but now in a more
complex anandd more constrained
operational environment.
A number of international professional
organisations do provide more
comprehensive guidance, framework
and worksheets around the IST process
to drive a more measureable or
quantitative approach. Some of these
include ASHRAE, NEBB, BCA (US)
and other Failure Modes and Effects
Analysis (FMEA) Tools.
This quantitative approach uses
traditional risk assessment
methodologies to normalise predicted
outcomes so the effect can be
measured with and without the
hierarchy of controls being provided.

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THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

What gets measured gets

managed

By using a standard platform that

weighs up severity, probability and
detectability, assurances can be given
that the right scenarios have been
addressed, the right mitigations have
been designed and finally the post-
construction forecasted operation
can be tested and recorded.
Using this methodology can provide the
design and construction team better
protection against exposure to fit for
purpose risks when an unexpected,
un-documented, very low probability
scenario occurs causing a services
interruption to the healthcare facility.
A properly defined quantitative IST
process may appear daunting for
large facilities but this process will
systematically eliminate issues and give
the IST, user acceptance and handover
more chance of success.

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Feels difficult now…but more

difficult later!

By subscribing to the rule of 90%

planning and 10% execution, the
IST process needs to start early
so the quantitative approach can
be developed, agreed and forecast
in construction programming. IST
scenario testing can then be scheduled,
tracked and flagged if progress and
milestones are not being achieved.
Skipping or compressing these steps
inevitably moves the process into the
more uncertain qualitative approach
and risks compromising the outcome
or pushes IST past practical completion
and into the operational phase of
the Health Facility. Compressing the
process places undue pressures on the
design and installation teams resulting
in:
- On-the-fly programing “hacks” or
“quick fixes” being implemented
and this makes it difficult for
post-construction trades to step
through ladder logic, SCADA or PLC
programming in the future
- Pressure to “solve it in software” -
whilst faster than modifying auxiliary
wiring, swapping relays or CT’s this
introduces more programming routine
complexity and makes it difficult for
building operators to understand why
some of the physical installation is not
installed as expected
- With high pressure, high potential
penalties and with testing occurring
late at night, rejection fatigue can
cause reluctant acceptance of
systems based on single scenario or
partial scenario success
- Finally, there is a risk that last minute
changes are not captured adequately
in writing, resulting in handover
documentation with fundamental
procedural requirements missed.
Gold Coast University Hospital

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Feels difficult now…but more

difficult later!

The key is not to rely on the defects

liability or warrantee period for
issues to be rectified. IST in the post-
occupancy phase introduces a number
of serious complexities:
- Testing is usually required to be
carried out after hours
- Rollback scenario planning needs to
be introduced to ensure if tests fail,
the facility can be returned to an
acceptable operational state
- Time consuming project management
is required to coordinate times, dates,
outage timings and notifications of
an increased number of occupants,
tenants and potentially the general
public
- Re-requesting the presence of
Mater Private Hospital Springfield, Health City – Springfield Central contractually required witness testing
parties adds project management
load
- Scheduled outages can be longer
than the designed uptime of
uninterruptable power supplies (UPS)
and other support systems, thus
further secondary measures may be
required
- Multiple planned outages may need
to be scheduled to comply with
operational time frames, resulting
in incremental testing as opposed to
robust overall systems testing
- System redundancies are typically
compromised during scheduled
outages thus reducing the facility
fault tolerance during the testing
period.
- A series of local temporary generators
and cooling maybe necessary to
support refrigeration, IT rooms and
other operational sensitive equipment
- Verification of operationally sensitive
Kempsey District Hospital
equipment once normal conditions
are returned

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

The start line has moved forward

With the move to intelligent buildings This single network topology has
and the rapid growth and development resulted in a shift of critical path
of the Internet of Things (IoT), an construction activities towards the
increasing number of devices are now information and communication
using LAN connected protocols such as technology (ICT) systems. With careful
Ethernet/IP, TCP/IP or MODBUS TCP to planning these systems need to be
communicate between systems. brought online and tested early in the
Increased usage of the IT networks process so sub-systems can then be
by these devices means that properly commissioned.
earlier completion, handover and It is effectively only at this point that a
commissioning of infrastructure and meaningful IST process can commence.
spaces that support this IT network Missing these milestones can result
is now required. These spaces include in testing being carried out on costly
cabling systems, switches, servers, temporary networks, essentially
datacentres, communications rooms contaminating the essence of the IST
and associated services that support process.
these including UPS, fire systems
including gaseous suppression and BMS
and Computer Room Environmental
Management Systems (CREMS).
This is further complicated by the
single or unified network trend in
healthcare facilities that provides very
sensible benefits including:
- a medical or finance grade level of
network redundancy for engineering
systems
- increased supplier options which are
not locked into one particular solution
(such as XML and HTTP)
- better inter-operability and data
sharing between systems
- more cost efficient installation
through reduce network duplication
(virtual segregation provided)
- higher data through-put capacity

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THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Keeping it green…not code blue

On top of the financial drivers for

best practise IST, the various green
building tools have acknowledged
that the inclusion of an independent
commissioning agent (ICA or CA) is
critical to the success of completed
healthcare facilities to meet their
aspirational design targets through
comprehensive commissioning.
Whilst approaching the problem
from a different angle, this same
ICA could also be the resource to
support the IST process due to their
intimate knowledge of the general
commissioning process.
By effectively embedding or hiring a
knowledgeable ICA, the value provided
to the project can far exceed the fee
sought through:
- a third party resource that provides
independence and unbiased findings
- does not get trapped into defending
“We recently commissioned our new Mater Springfield Private the design or installation without
Hospital. This is a technology rich facility. As engineering seeing the bigger picture
systems and technology become increasingly complex and - provides testing, commissioning and
converged, the traditional approach of different disciplines maintenance suggestions during the
commissioning in silos no longer works. We engaged Aurecon design phase
as an independent commissioning agent, with a specific focus - reviews testing plans, equipment
on integrated commissioning. This provided us with assurance selections and interfaces between
that when the hospital went live everything would come systems to minimise gaps between
design and construction parties
together it would be safe and operate as designed.”
- removes the subjective or qualitative
approach to commissioning and IST
Joanna Vasiliou, Director Built Environment & Program Director Mater
- implements post occupancy
Private Hospital Springfield, Mater Health Services
operational and seasonal (summer
and winter) building tuning (to
optimise energy and water usage)
during the post-handover phase

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Simple in design, simple in

operation

With all good intentions the increasing

drive for stakeholders and design
teams to account for every conceivable
failure scenario and for each of these
scenarios to be actioned with a fully
automated responses can introduce a
high level of operational complexity.
These complex scenarios often
with a low probability of occurring
compound into more complex
programming, logic analysis and
sophisticated interdependencies.
This might drive counterintuitive
routines during operation making the
facility hard to operate, less likely to
be understood and less trusted by
facility management teams in times of
operational crisis.
Some realities that may not have been
considered in this catch all approach Sunshine Coast University Hospital
include:
- Not enough time and effort placed on
the training of operational phase staff
to learn and understand the system
and its responses
- Consideration of the availability of
suitably skilled operators onsite to
run the facility - the days of a team of
resident hospital engineers has long
passed
- Operators are commonly not given a
change to drive the system prior to
the facility becoming operationally
“live”
- Operator skill and confidence
correlates well with their trust in the
system when a genuine multi-failure
scenario is presented. For new staff
or unskilled operators encountering
a multi-failure scenario, often panic
can set in…resulting in systems being
reverted to ‘manual mode’, rendering
all sophisticated automation
redundant and compounding the
Mater Private Hospital Springfield, Health City – Springfield Central
probability of human error

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Simple in design, simple in

operation

Thought should be given to simplifying

design and operation of these types of
systems with one view to only address
realistic / high probability / real
world failure events with automated
responses implemented.
Other more left field scenarios should
be addressed with manual intervention,
properly articulated in operating and
maintenance procedures that can be
risk assessed and carried out by the
team on the ground when/if they ever
occur.
Furthermore it is common for building
owners / operators to be met with very
high re-programming costs to change
system functionality when it is finally
discovered it is too complicated to
manage.
Wagga Wagga Health Service (WWHS) Redevelopment Project

Kempsey District Hospital

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 THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES

Repeating themes

Human error is often at the core of

unplanned healthcare facility services
disruption, however a number of
repeated technical deficiencies can
contribute to this as well. These are
often due to improper coordination
and calibration of protective devices,
sensing, signalling, wiring or design
coupled with human error from largely
using a more qualitative approach to
IST in final testing and handover.
Some commons trends for areas for
improvement and extra scrutiny of
IST and commissioning generally in
healthcare facilities are summarised as
follows.
High voltage networks and control
systems
- Programming of high voltage relays
has been incorrect, incomplete and
altered without record contributing
to unplanned outages and prolonged
rectification time
- Only testing for “simulated” rather
than “true” physically initiated mains
and generator failures has resulted in
unplanned outages
- Not testing closer to full load
scenarios with standard / isolation
/ step transformers and generators
and the effect of inrush currents on
upstream and downstream protection
has resulted in unplanned outages
- Not testing generators at full load on
site within the nominated room i.e.
with installed cooling and only relying
on the FAT simulated conditions
has highlighted shortcomings in
machine cooling and room ventilation
performance
- Sensitive protection elements such as
ROCOF (rate of change of frequency)
need to be tuned to site specific

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THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES
Repeating themes
conditions which are seldom present
using temporary/dummy loads. Thus
improper settings may be established,
increasing the likelihood of unplanned
outages post occupancy when real
building systems are operational.
Low voltage networks and control
systems
- Full load UPS (or emergency lighting)
battery discharge testing not being
carried out thus not identifying bad
DC batteries and poor DC connections
- Incomplete testing to save time for
full cycle load shedding and return
to mains scenarios of LV boards
that resulted in some LV boards not
returning from load shed state
- True feedback status from load shed
contactor / motor operated breakers
- Transient response of systems that
can’t be simulated with dummy loads
and may cause inadvertent protective
device operation due to transients
and load steps during switching.
For example generator set systems
needs time to stabilise following
connection of transformers and
starting of larger motors such as fire
services pumps etc.
Fire services
- Sufficient time to test complex fire
evacuation strategies driven by
fire engineered solutions. This can
introduce complex system operations
when cascading evacuation from
zone to zone and even more complex
operation when carried out in partial
and full loss IST scenarios
Hydraulics services
- Provide sufficient time to testing
CSSD sterilisation equipment with
available potable water sources to
ensure Vendor acceptance
Mechanical services -F
 unctional testing of wandering
- Provide sufficient time to test patient and mother baby protection
differential air pressures across systems to confirm interoperability
clean/dirty boundary of sterilisation of security, nurse call and location
equipment accuracy of asset tracking systems.
Vertical Transport
- Only full integrated systems testing
will confirm the availability of -S
 ystem interfaces with security and
essential power supply to smoke other services for functionality of
management systems. lockdown, fire mode, movement of
- Full IST will confirm auxiliary systems dangerous goods, mortuary body
that support critical infrastructure movement and code call procedures.
actually function in as designed BMS
- Full load and low load testing of -M
 onitoring and alerting, confirming
central plant systems as well as the registration of alerts at the
the performance of this equipment appropriate priority level for various
in redundant (n+1, 2n, n + n etc.) systems. Improper priority settings
configuration can result in critical alarms being
ICT systems missed (such as lab fridges) and
unplanned failure of subsequent
- Testing the ability of the HVAC system systems.
to deliver effective room and rack
airflow in datacentres once room is
populated with selected racks, servers
and other equipment
- The correct operation of high
level interfaces between audio-
visual systems and other systems
such as lighting control, patient
entertainment, blind control, DALI
and AMX can be time consuming to
commission and may impact IST.
- Operation of emergency and code
calls of nurse call system and
subsequent sequence of notification,
escalation and response procedures.
- Failover functionality of network
equipment, proving up of network
self-healing capabilities.
- Function of fixed and mobile duress
systems and subsequent sequence of
notification, escalation and response
procedures.
THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES p 15
THINKING INTEGRATED SYSTEMS TESTING OF HEALTHCARE FACILITIES
Where to next?
A robust approach to integrated
commissioning can and should be
followed today. The success of the IST
process can be improved by:
- using a more quantitative approach
rather than relying on a qualitative
methods
- simplifying the design of the facility
failure modes and interfaces to reduce
operational complexity
- using readily available independent
commissioning agents to manage and
track process
- acknowledging that IT networks are a
critical starting point to commission
before IST can commence
IST is not a new concept and even in a
volatile construction industry and an
increasingly technologically advanced
healthcare sector, a well-designed,
logical, managed and properly
implemented quantitative IST process
will help hit the traditional project
delivery metrics of time, cost and
quality.
South Australia Medical Research Institute
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But what next? What will our hospitals New roles, new technology, new
and health system look like in the processes, new standards, new
future? What could commissioning look relationships for commissioning
like in the future? hospitals need to be designed.
We know that the increasing cost Aurecon is engaging with our clients
of health is unsustainable. As our and the industry to design and bring
populations grow and age, the pressure new ideas to life for commissioning and
on our health system will continue to we invite others to join us.
mount. Aurecon – Bringing ideas to life.
We believe that to help address the
pending health affordability gap the
shape of our health system and the
hospitals must change. A far more
integrated approach to planning,
delivery and operation across health
services, buildings and technology will
be needed to support this.
Technology will inevitably have
an increasing role to play. With an
even great level of integration and
dependency on technology ahead,
we believe new approaches to
commissioning are needed.
About Aurecon
Aurecon provides engineering, management and
specialist technical services for public and private
sector clients globally. With an office network
extending across 25 countries, Aurecon has been
involved in projects in over 80 countries. We seek
to foster human achievement in all aspects of our
work
Aurecon offices are located in:
Angola, Australia, Botswana, China, Ghana,
Hong Kong, Indonesia, Kenya, Lesotho, Macau,
Malawi, Mozambique, Namibia, New Zealand,
Nigeria, Philippines, Qatar, Singapore, South Africa,
Swaziland, Tanzania, Thailand, Uganda,
United Arab Emirates, Vietnam.

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