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Case study : assessment of innovation on a P3 project product perspective D’Alençon Moya, Verónica 2013

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CASE STUDY: ASSESSMENT OF INNOVATION ON A P3 PROJECT PRODUCT PERSPECTIVE  by Ver?nica D?Alen?on Moya B.Sc., Universidad Diego Portales, 2008  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF APPLIED SCIENCE  in  The Faculty of Graduate and Postdoctoral Studies  (Civil Engineering)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   November 2013 ? Ver?nica D?Alen?on Moya, 2013 ii  Abstract  Innovation plays an important role in the construction industry and associated product and service supplies. Novel ideas in terms of design concepts, technologies and materials techniques for design, construction, and supply chain are being developed constantly in order to be more efficient in terms of resource usage to save time and money.  An assessment of innovation is performed for the three proposals submitted for the Interior Heart and Surgical Centre building (IHSC) in Kelowna, BC. This project is being developed under a private public partnership contract between the Government of British Columbia and Plenary Group.   Specifically, this thesis is focused on the product perspective, which relates to design aspects? the form and layout of the facility. The following definition of innovation was used in this study; ?The use of advanced technologies, methodologies, and clever ideas that result in a positive incremental change compared to the indicative design?. In order to assess innovation, this definition was applied to four specific items of each proposal: enhancement of patient safety, optimization of clinical utilization, an enhanced wellness environment, and enhancement of site development features.   iii  Preface  The assessment of innovation of the Interior Heart and Surgical Center (IHSC) was made possible through a collaboration with Partnerships BC, who provided access to the information necessary for the study.  This thesis is focused on the product perspective, which relates to design aspects? the form and layout of the facility. Refer to Melej 2013 in order to complement this work with a process dimension of the assessment of innovation for the IHSC project.     iv  Table of contents  Abstract .......................................................................................................................................... ii Preface ........................................................................................................................................... iii Table of contents .......................................................................................................................... iv List of tables....................................................................................................................................x List of figures ............................................................................................................................... xii List of abbreviations .................................................................................................................. xvi Glossary .................................................................................................................................... xviii Acknowledgements ......................................................................................................................xx Dedication ................................................................................................................................... xxi Chapter  1: Thesis overview ....................................................................................................... 1 1.1 Introduction ................................................................................................................. 1 1.2 Motivation and background ........................................................................................ 2 1.3 Objectives ................................................................................................................... 4 1.3.1 Research challenges ................................................................................................ 5 1.4 Methodology ............................................................................................................... 6 1.5 Literature review ....................................................................................................... 19 1.5.1 Public private partnerships .................................................................................... 19 1.5.2 Innovation ............................................................................................................. 21 1.5.3 Factors allowing or hindering innovation ............................................................. 24 1.5.4 Experience in P3 health care projects in Australia, U.K and Canada ................... 26 1.6 Project overview ....................................................................................................... 32 v  1.7 Contribution to the work ........................................................................................... 35 1.8 Thesis structure ......................................................................................................... 36 Chapter  2: Assessment of innovation through indicative design and proposal characterization................................................................................................................................................... 37 2.1 Indicative design ....................................................................................................... 38 2.2 Description of proponents proposals ........................................................................ 47 2.2.1 Proponent 1 ........................................................................................................... 47 2.2.2 Proponent 2 ........................................................................................................... 49 2.2.3 Proponent 3 ........................................................................................................... 51 2.3 Proposal analysis ....................................................................................................... 53 2.3.1 Enhance patient safety (RFP 3.2.1.4).................................................................... 53 2.3.1.1 Enhance patient safety ? requirements ......................................................... 56 2.3.1.1.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs). (RFP 3.2.1.4 a). ........................................... 56 2.3.1.1.2 Travel efficiency measurement; patient transport routes (via elevators) (RFP 3.2.1.4 b) .......................................................................................................... 58 2.3.1.1.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms (RFP 3.2.1.4 c)  ................................................................................................................. 58 2.3.1.1.4 Ability to safely monitor patients in the following areas (RFP 3.2.1.4 d) ..    ................................................................................................................. 59 2.3.1.2 Enhance patient safety - assessment of innovation ....................................... 60 vi  2.3.1.2.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs). ...................................................................... 60 2.3.1.2.2 Travel efficiency measurement; patient transport routes (via elevators) 63 2.3.1.2.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms (3.2.1.4 c) RFP)  ................................................................................................................. 64 2.3.1.2.4 Ability to safely monitor patients in the following areas (RFP 3.2.1.4 d) ..    ................................................................................................................. 68 2.3.2 Optimize clinical utilization (RFP 3.2.1.5) ........................................................... 70 2.3.2.1 Optimize clinical utilization - requirements ................................................. 72 2.3.2.1.1 Location of storage spaces (RFP 3.2.1.5 b)............................................. 72 2.3.2.1.2 Separation and efficiency of flows: public, patients and materials (RFP 3.2.1.5 c)  ................................................................................................................. 73 2.3.2.1.3 Workflow within medical device reprocessing (MDR) (RFP 3.2.1.5 d) 74 2.3.2.2 Optimize clinical utilization - assessment of innovation .............................. 76 2.3.2.2.1 Location of storage spaces (RFP 3.2.1.5 b)............................................. 76 2.3.2.2.2 Separation and efficiency of flows: public, patients and materials (RFP 3.2.1.5 c)  ................................................................................................................. 79 2.3.2.2.3 Workflow within medical device reprocessing (MDR) (RFP 3.2.1.5 d) 81 2.3.3 Wellness environment (RFP 3.2.1.6) .................................................................... 84 2.3.3.1 Wellness environment ? requirements .......................................................... 84 2.3.3.1.1 Access and quality of direct natural light for each room listed in table below (RFP 3.2.1.6.a.i, ii, iii) ................................................................................... 84 vii  2.3.3.2 Wellness environment - assessment of innovation ....................................... 86 2.3.3.2.1 Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR (RFP 3.2.1.6.a.i) ..................................... 86 2.3.3.2.2 Availability of borrowed and/or direct natural light as defined by the IHSC light measurement methodology document for each room as listed below (RFP 3.2.1.6.a. ii) ...................................................................................................... 89 2.3.3.2.3 Access to outdoor space (exterior courtyard or roof garden) from staff lounges (RFP 3.2.1.6.a.iii) ........................................................................................ 91 2.3.4 Enhance site development features (RFP 3.2.1.7) ................................................ 92 2.3.4.1 Enhance site development features ? requirements ...................................... 93 2.3.4.1.1 Site parking and vehicular flows (RFP 3.2.1.7 b) ................................... 93 2.3.4.2 Enhance site development features - assessment of innovation. .................. 93 2.4 Conclusions ............................................................................................................... 98 Chapter  3: Conclusions .......................................................................................................... 105 3.1 Chapter overview .................................................................................................... 105 3.2 Objectives ............................................................................................................... 105 3.3 Research Methodology ........................................................................................... 106 3.4 Challenges ............................................................................................................... 108 3.5 Summary of conclusions ......................................................................................... 109 3.5.1 Product perspective analysis ............................................................................... 111 3.5.2 Product perspective ............................................................................................. 112 3.5.2.1 Enhance patient safety ................................................................................ 112 viii  3.5.2.1.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs). .................................................................... 112 3.5.2.1.2 Travel efficiency measurement; patient transport routes (via elevators) ....    ............................................................................................................... 113 3.5.2.1.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms ....... 113 3.5.2.1.4 Ability to safely monitor patients .......................................................... 113 3.5.2.1.5 Enhance patient safety ? summary ........................................................ 114 3.5.2.2 Optimize clinical utilization ........................................................................ 114 3.5.2.2.1 Location of storage space ...................................................................... 114 3.5.2.2.2 Workflow within medical device reprocessing ..................................... 114 3.5.2.3 Wellness environment ................................................................................. 115 3.5.2.3.1 Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR .............................................................. 115 3.5.2.3.2 Availability of borrowed and/or direct natural light as defined by the IHSC light measurement methodology ................................................................... 115 3.5.2.3.3 Access to outdoor space (exterior courtyard or roof garden) from staff lounges  ............................................................................................................... 116 3.5.2.4 Enhance site development features ? .......................................................... 116 3.5.2.4.1 Site parking and vehicular flows ........................................................... 116 3.6 Analysis of the results ............................................................................................. 117 3.7 Future Work ............................................................................................................ 124 References ...................................................................................................................................125 ix  Appendices ..................................................................................................................................127 Appendix A: Indicative design ..................................................................................................128 Appendix B: Enhance patient safety ........................................................................................135 Appendix C: Optimize clinical utilization ...............................................................................162 Appendix D: Wellness environment .........................................................................................188 Appendix E: Enhance site development features ....................................................................195    x  List of tables  Table 1.1 Items to review in each proposal product view ............................................................ 10 Table 1.2 Items to review in product view ................................................................................... 13 Table 1.3 Product performance metrics ........................................................................................ 18 Table 1.4 Summary of benefits and innovations identified in value for money reports produced by Partnerships BC for health care projects .................................................................................. 31 Table 2.1 Product view ................................................................................................................. 37 Table 2.2 Indicative design measurements (m) ............................................................................ 41 Table 2.3 Product view performance metrics ............................................................................... 46 Table 2.4 Travel distances for surgical staff to patient ................................................................. 56 Table 2.5 Travel distances for patient transport from cardiac Ors ............................................... 58 Table 2.6 Travel distance summary surgical staff to patient ........................................................ 62 Table 2.7 Travel distance summary patient transport routes ........................................................ 64 Table 2.8 Standardization requirements ....................................................................................... 67 Table 2.9 Sight lines requirements from unit clerk location to all viewable decentralized care stations .......................................................................................................................................... 69 Table 2.10 Sight lines requirements from unit clerk location to all viewable head of patient beds....................................................................................................................................................... 70 Table 2.11 Travel efficiency distance to storage space ................................................................ 72 Table 2.12 Travel efficiency distance from medical device reprocessing (MDR) ....................... 75 Table 2.13 Summary travel distances to storage spaces ............................................................... 77 Table 2.14 Number of storage locations for each travel route ...................................................... 79 xi  Table 2.15 Efficiency of flows of public, patient and logistics .................................................... 81 Table 2.16 Average distances from MDR .................................................................................... 81 Table 2.17 Criteria to evaluate access and quality of direct natural light ..................................... 85 Table 2.18 Number of rooms with direct access to natural light .................................................. 88 Table 2.19 Number of rooms with access to borrowed and/or direct light ................................... 90 Table 2.20 Designated parking ..................................................................................................... 97 Table 2.21 Product summary metrics ......................................................................................... 104 Table 3.1 Potential innovation .................................................................................................... 110 Table 3.2 Product summary ........................................................................................................ 123  xii  List of figures  Figure 1.1 Methodology of this study ............................................................................................. 7 Figure 1.2 Project site plan ........................................................................................................... 32 Figure 2.1 Indicative design building elevations N/E/S/W faces ................................................. 39 Figure 2.2 Relative corridor efficiency and travel efficiency distance formulas .......................... 41 Figure 2.3 Proponent 1 building elevations N/E/S/W faces ......................................................... 48 Figure 2.4 Proponent 2 building elevations N/E/S/W .................................................................. 50 Figure 2.5 Proponent 3 building elevations N/E/S/W .................................................................. 52 Figure 2.6 Linear relationship score/distance ............................................................................... 55 Figure 2.7 Travel efficiency distances .......................................................................................... 57 Figure A1 Indicative design site plan ......................................................................................... 129 Figure A2 Indicative design level 1 ............................................................................................ 130 Figure A3 Indicative design level 2 ............................................................................................ 131 Figure A4 Indicative design level 3 ............................................................................................ 132 Figure A5 Indicative design level 4 ............................................................................................ 133 Figure A6 Indicative design level 1 ............................................................................................ 134 Figure B1 Proponent 1 travel distance Pre Op to OR level 1 and 2 ........................................... 136 Figure B2 Proponent 1 travel distance PARR to Pre-Op level 1 and 2 ...................................... 137 Figure B3 Proponent 1 travel distance Pre-Op to OR lounge level 2 ......................................... 138 Figure B4 Proponent 2 travel distance Pre-Op to OR lounge level 1 ......................................... 139 Figure B5 Proponent 2 travel distance Pre-Op to OR lounge level 2 ......................................... 140 Figure B6 Proponent 2 travel distance PARR to Pre-Op lounge level 1 .................................... 141 xiii  Figure B7 Proponent 2 travel distance PARR to Pre-Op lounge level 2 .................................... 142 Figure B8 Proponent 2 travel distance OR to Staff lounge level 1 ............................................. 143 Figure B9 Proponent 2 travel distance OR to staff lounge level 2 ............................................. 144 Figure B10 Proponent 3 overall floor level 1 A ......................................................................... 145 Figure B11 Proponent 3 overall floor level 1 B .......................................................................... 146 Figure B12 Proponent 3 patient safety level 1 A ........................................................................ 147 Figure B13 Proponent 3 patient safety level 1 B ........................................................................ 148 Figure B14 Proponent 3 patient safety level 2 A ........................................................................ 149 Figure B15 Proponent 3 patient safety level 2 B ........................................................................ 150 Figure B16 Proponent 1 travel distance from Pre-Op to clean utility level 1 and cardiac OR to CSIUC level 2 ............................................................................................................................. 151 Figure B17 Proponent 1 travel distance from Pre-Op to OR ...................................................... 152 Figure B18 Proponent 1 travel distance from OR to PARR ....................................................... 153 Figure B19 Proponent 2 travel distance from OR to PARR ....................................................... 154 Figure B20 Proponent 2 travel distance from OR to CSICU ..................................................... 155 Figure B21 Proponent 2 travel distance from Pre-Op to OR level 1 .......................................... 156 Figure B22 Proponent 2 travel distance from Pre-Op to OR level 2 .......................................... 157 Figure B23 Proponent 1 sightlines from unit clerk to decentralized care station ....................... 158 Figure B24 Proponent 2 sightlines from unit clerk to decentralized care station ....................... 159 Figure B25 Proponent 1 sightlines from unit clerk to head of patients beds .............................. 160 Figure B26 Proponent 2 sightlines from unit clerk to head of patients beds .............................. 161 Figure C1 Proponent 1 distances from OR to equipment storage room and PARR to clean utility..................................................................................................................................................... 163 xiv  Figure C2 Proponent 2 storage spaces in OR restricted corridor................................................ 164 Figure C3 Proponent 3 clinical optimization level 2 B............................................................... 165 Figure C4 Proponent 1 clinical optimization level 2 .................................................................. 166 Figure C5 Proponent 2 housekeeping room in surgical restricted corridor ................................ 167 Figure C6 Proponent 2 soiled utility room in surgical restricted corridor .................................. 168 Figure C7 Proponent 3 floor plan clinical utilization level 1 A .................................................. 169 Figure C8 Proponent 3 floor plan clinical utilization level 1 B .................................................. 170 Figure C9 Proponent 3 floor plan clinical utilization level 2 A .................................................. 171 Figure C10 Proponent 3 floor plan clinical utilization level 2 B ................................................ 172 Figure C11 Proponent 2 from ORs to soiled utility room .......................................................... 173 Figure C12 Proponent 1 optimized clinic utilization flow level 1 to 3 ....................................... 174 Figure C13 Proponent 2 circulation flows level 1 ...................................................................... 175 Figure C14 Proponent 2 circulation flows level 2 ...................................................................... 176 Figure C15 Proponent 2 circulation flows level 3 ...................................................................... 177 Figure C16 Proponent 2 circulation flows level 4 ...................................................................... 178 Figure C17 Proponent 3 floor plan clinical utilization level 1 A ................................................ 179 Figure C18 Proponent 3 floor plan clinical utilization level 1 B ................................................ 180 Figure C 19 Proponent 3 floor plan clinical utilization level 2 A ............................................... 181 Figure C20 Proponent 3 floor plan clinical utilization level 2 B ................................................ 182 Figure C21 Proponent 3 floor plan clinical utilization level 3 A ................................................ 183 Figure C22 Proponent 3 floor plan clinical utilization level 3 B ................................................ 184 Figure C23 Proponent 1 optimized clinical utilization MDR flows level 3 ............................... 185 Figure C24 Proponent 2 optimized clinical utilization decontamination zone ........................... 186 xv  Figure C25 Proponent 2 optimized clinical utilization MDR flows sterile zone ........................ 187 Figure D1 Proponent 1 floor plan direct natural light level 1-2-3 .............................................. 189 Figure D2 Proponent 2 daylight and light tube in PARR ........................................................... 190 Figure D3 Proponent 2 CSICU daylight ..................................................................................... 191 Figure D4 Proponent 2 daylight in Pre-Op/stage II recovery room ............................................ 192 Figure D5 Proponent 2 daylight in the level 1 staff lounge ........................................................ 193 Figure D6 Proponent 2 daylight in MDR ................................................................................... 194 Figure E1 Proponent 1 parking and vehicular access ................................................................. 196 Figure E2 Proponent 2 parking spaces. ....................................................................................... 197 Figure E3 Proponent 2 emergency routes. .................................................................................. 198 Figure E4 Proponent 3 circulation plan. ..................................................................................... 199 Figure E5 Proponent 3 parking plan ........................................................................................... 200  xvi  List of abbreviations  P3  Public private partnership IHSC  Interior Heart and Surgical Centre building  PFI  Private finance initiative VfM  Value for money RFQ  Request for qualifications RFP  Request for proposal  LEED? Leadership in energy and environmental design  NPC  Net present cost  DB  Design build  DBB  Design-bid-build DBM   Design-build-maintain  BOOT  Build-own-operate-transfer  DBFM  Design-build-finance-maintain  DBFMO Design-build-finance-maintain-operate BTO  Build-transfer-operate  O&M   Operation and maintenance  CSICU  Cardiac surgery intensive care unit xvii  MDR   Medical device reprocessing OR   Operating room PARR   Post-anesthetic recovery room                 xviii  Glossary  Public private partnership: Is a partnership between the government and the private sector, in which the private sector concessionaire builds and finances a facility and may also be contracted to provide facility management and maintenance services over a long term period (Siemiatycki and Farooqi 2012). Private finance initiative: (Public private partnership on the UK) Several private sector partners form a consortium to deliver capital assets and some services to a hospital trust on a long-term contract, generally lasting 30 years or more (Barlow and K?berle-Gaiser 2008). Request for qualifications: Document issued by an owner inviting parties interested in participating in an RFP, to submit their qualifications for delivering a project (Partnerships British Columbia 2012). Request for proposal (RFP) : Document issued by an owner for qualified proponents to submit formal proposals to deliver a project (Partnerships British Columbia 2012). Design-bid-build (DBB): This is a traditional delivery model where an architect is retained by the owner to develop a detailed design for the building. Once the working drawings are complete, a tender call for a construction contract is issued. Typically, the lowest qualified price is selected and an industry standard construction contract is used. The construction contractor takes responsibility for constructing the building to the specifications detailed in the working drawings. The owner retains key design and construction risks, for example, schedule, construction cost and life cycle maintenance costs. In this model, since separate parties design, build and maintain the building, cooperation between consultants and contractors can be less xix  than ideal, and the opportunities for integration in design, construction and maintenance are not always maximized (Partnerships British Columbia 2010). Design-build-maintain (DBM): The public sector owns, operates and finances the project but engages a private partner to design, construct and maintain the facility for a specific period of time (Partnerships British Columbia 2005). Design-build-finance-maintain (DBFM): The private sector designs, builds and finances an asset and provides maintenance services under a long-term agreement (The Canadian Council for Public-Private Partnerships 2003).  xx  Acknowledgements  First, I am very grateful to my supervisor, Dr. Alan D. Russell for his support and many hours of his time. I could not have come to this stage without his help and guidance when difficulties arouse during my masters program. I would also like to thanks Dr. Sheryl Staub-French for reviewing this work.  Special thanks to Partnerships BC for providing all the information to make possible this research, especially Ms. Sarah Clark and Mr. Doug Ewing to for their time and cooperation.  Finally, I am sincerely grateful to my family for their love and support throughout this process and my friends in Canada and Chile. xxi  Dedication  To my dear friends and family  To my parents, my sisters and nephews  For their love and support  To Nicol?s  For your love, patience, motivation and support  1  Chapter  1: Thesis overview   1.1 Introduction This work constitutes one part of a two part study directed at product and process innovations in a health care project and whether or not the adoption of a P3 procurement mode stimulates innovation because of the design competition inherent in such a mode. Only the product dimension is treated in this thesis, and then only within the context of the efficiency of health services delivery and wellness outcomes. A broad understanding of all study findings requires the review of both this thesis and that of Melej 2013. This approach was adopted to ensure compliance with the University of British Columbia?s Faculty of Graduate and Postdoctoral Studies policy of independence amongst theses.  Important questions that arise during the bidding process when owners or their agents evaluate proposals include: (i) how to identify, measure and evaluate the innovation included in a proposal; and, (ii) whether or not innovation should be treated as a stand-alone evaluation criterion. These questions are specifically relevant in project procurement using a public private partnership (P3) arrangement, since this format of procurement gives the private partner the opportunity to be more creative because of the ability to make tradeoffs between capital and future costs, compared with other procurement modes such as design-build-bid (DBB) or design-build (DB).    2  A key question related to the use of a P3 procurement mode and the topic of innovation is ?Do proposals submitted in response to an RFP for a project procured using a P3 procurement mode reflect innovation in one or both of the product (design) and process (construction) dimensions of a project?? Accompanying this fundamental question are others dealing with what constitutes innovation, how does it relate to project performance, how can it be measured, what are its primary drivers, etc.   In this thesis, an assessment of innovation offered in response to a request for proposals (RFP) is provided for the three proposals submitted for the Interior Heart and Surgical Centre (IHSC) building in Kelowna, BC plus the indicative design. As of 2013, the IHSC project is currently under development under a private public partnership contract between the Government of British Columbia and Plenary Group.  1.2 Motivation and background The motivation for the study is to explore the hypothesis that ?P3 procurement generates innovation?, and in turn incremental value, as measured in terms of value for money criteria as well as other metrics of interest to the client and facility end users. The methodology employed is one of an in-depth case study of the proposals of an actual project.  A P3 is a partnership between the government and the private sector, in which the private sector concessionaire builds and finances a facility and may also be contracted to provide facility management and maintenance services over a long term period (Siemiatycki and Farooqi 2012).  3  The purpose of a P3 arrangement is to extract the strengths, skills and best ideas from both the public and private partners. From a public sector viewpoint, the main advantage of a P3 is the ability to transfer more of the risks to the private sector as well as achieve value for money.  Value for money (VfM) is a broad term that captures both the quantitative and qualitative benefits that are expected to be achieved by the decision to deliver the project using the partnership method (Partnerships British Columbia 2012).  With respect to health care facilities, public hospitals worldwide are facing a financial crisis, mainly because of rising costs and public budget constraints. It is argued by the proponents of P3 procurement that it has the potential to provide innovative ways to control costs and improve service. P3 procurement for healthcare facilities  can take many forms, each with a different degree of private sector responsibility and risk (Taylor 2002).  According to The Canadian Council for Public-Private Partnerships (2013) P3s in the health care sector are seen mainly in countries with national health services. Each of these countries makes use of different procurements modes, Australia being the one with the widest ranges of models. On the other hand, the private finance initiative in the United Kingdom is focused on the use of a design-build-finance-maintain (DBFM) model. Similar models have been adopted in Canada, Portugal and Spain. The selection of the most appropriate structure must be based on the goals desired by the public sector as well as reflect private sector capabilities.   4  P3 for the healthcare sector is the most active in Canada according to the Canadian Council for Public-Private Partnerships. As of 2013, there are 71 of those projects in Canada.  1.3 Objectives The primary purpose of this thesis is to evaluate and assess the innovation included (if any) in the three short-listed proposals submitted for the IHSC project with respect to the product perspective. To help identifying potential innovations and cope with the volume of information that needed to be reviewed, it was considered that areas of important difference in scoring between the proposals could be an indication of innovation.  Specific thesis objectives are: 1. Present information about innovation as it relates to health care services delivery and wellness outcomes (versus the design and construction of health care facilities to enhance constructability and to reduce life cycle cost). 2. Present a methodology that helps with the tasks of identifying and assessing innovation in project proposals and identify specific innovations for the project assessed in this thesis. 3. Seek to determine if innovation was the source of a significant difference in score amongst proposals for an individual criterion and overall project ranking for the project studied.   5  1.3.1 Research challenges A number of challenges were encountered in executing the research. An important one is related to the fact that assessing innovation in construction projects can be a subjective task, since depending on the individuals or the context involved, the same idea or methodology could be considered innovative or not.   Another important challenge deals with the amount and type of information available. Assessing innovation in proposals involves reviewing, analyzing and characterizing the indicative design and all proposals submitted. As part of the information that accompanies proposals is deemed to be sensitive or confidential, generally the picture available for analysis is not complete or the information cannot be presented directly. The information used for the development of this study comes from two sources; information publically available and Interior Health Authority information given by Partnerships BC.  The information provided from the Health Authority and facilitated by Partnerships BC relevant to the focus of this thesis included: RFP (Request for proposal), project agreement, design guidelines, technical submissions of the three proponents, indicative design and the evaluation report. Not provided were the proponent financial submissions.  The limited access to information and the different ways that proposal details were presented by each proponent made challenging the tasks of identifying and comparing differences between proposals.  6  1.4 Methodology The product view relates to project design aspects? the form and layout of the facility, choice of systems and the manner in which systems are interfaced.   Under the product view the following items of the RFP are analyzed: ? 3.2.1.4 Enhance patient safety (SI)1 ? 3.2.1.5 Optimize clinical utilization (SI) ? 3.2.1.6 Wellness environment (SI) ? 3.2.1.7 Enhanced site development features (SI)  Developed in Chapter 2 of this study is a comparison between the proposals received and the indicative design in terms of product view. This chapter presents the information (facts) included in the proposals submitted by the IHSC project, as well as the information included in the RFP. Facts quoted directly from these sources are shown in italics.                                                  1 Scored Item on PBC?s score sheet 7   Figure 1.1 Methodology of this study  In Figure 1.1 is shown the methodology of this study and the steps followed which are described in the following section.  ? Meetings: Meetings were conducted with Partnerships BC to discuss the scope of the work and to clarify information facilitated by them. The participants of the meetings were Ms. Sarah Clark president and CEO of Partnerships BC and Vice President Mr. Doug Ewing, Vice President.   8  ? Literature review: An extensive review of academic and practitioner documentation was conducted. The review and analysis of the literature is presented in: 1.5.1 Public private partnerships, section 1.5.2 Innovation, section 1.5.3 Factors allowing or hindering innovation and 1.5.4 Experience in P3 health care projects in Australia, U.K and Canada. In terms of public private partnerships, topic treated include; history of P3, case studies, and P3 and its application in Canada and other countries. The topic of innovation was studied in some detail in order to know what research has been conducted and to help to develop a specific definition of innovation that can be applied in this study. ? Definition of innovation for the purpose of this project: In order to identify novel ideas in each proposal, a working definition of innovation is needed. To qualify as an innovation that can be attributed, at least in part to the choice of procurement mode, it must not be a common feature in similar facilities independent of procurement mode used. For example, many of the benefits/innovations could be present, irrespective of procurement mode used.  As explained further in this document, innovation has different definitions according to a specific context. For the purpose of this study, a definition of innovation based on Russell, Tawiah, and de Zoysa (2006) was defined as ?The use of advanced technologies, methodologies, and clever ideas that result in a positive incremental change compared to the indicative design?. This definition assisted in identifying and comparing novel ideas or creative concepts contained in each proposal for the IHSC project. In some cases, this process requires the exercise of judgment on the part of the researcher as to whether innovation is present. 9  ? Proposals and indicative design review: To comprehend the requirements of the Health Authority and the IHSC project, an analysis of the three proposals and the indicative design was performed. ? Assessing innovation: An assessment of innovation from a product view is presented in Chapter 2. This assessment consists of a review of selected items in the documentation submitted in response to the RFP (Table 1.1), and the application of judgment to classify the solutions as being innovative, according to the definition of innovation stated previously. Of particular interest was the concept of relative innovation ? i.e. differences in features/solutions amongst the proposals submitted and between the proposals submitted and the indicative design.  Also in aid of identifying innovation, each proposal is compared to the indicative design. For purposes of this study, the indicative design provides the starting point ? it is a design that fulfills or exceeds in some cases the minimum requirements stated in the RFP. It is noted that information associated with the indicative design is not as complete as what was submitted by the private sector proponents (e.g. construction schedule). As stated previously, proponent information related to pricing and financial arrangements was not made available.    10  Presented in Table 1.1 are the items under the product view analyzed:  Product view 3.2.1.4 Enhance patient safety (SI)2 3.2.1.5 Optimize clinical utilization (SI) 3.2.1.6 Wellness environment (SI) 3.2.1.7 Enhanced site development features (SI) Table 1.1 Items to review in each proposal product view  Prior to examining in depth how scoring was assigned for the items in Table 1.1, it is useful to first overview the schema for scoring proposals as defined in the RFP. This overview provides some insights into how the scoring structure likely guided proponents in their search for a winning solution. It is important to mention is that there may be a relationship between innovation and score, however, while innovation might be present, it does not necessarily lead to a superior score. Having said that, in the value for money report for the IHSC facility (Partnerships British Columbia 2012), a linkage is forged between innovation and the highest scored proposal.                                                    2 Scored Item on PBC?s score sheet 11  The scoring system contained in the request for proposal (RFP) is presented below, along some comments presented in italics. 1. The net present cost of the maximum period payments as at the submission time for financial submissions must not exceed the affordability ceiling. [This number was not specified in the RFP, it was not made available to the research team, and proponent values submitted were not provided to the research team.]  2. The total facility development and capital costs (NPC) of the proposal as at the submission time for financial confirmation must not exceed $128.17 million (nominal).  3. To achieve the affordability limits, a scope ladder was specified if required. [The proposals submitted did not use the scope ladder].  4. For all proposals that rank equally in terms of scope ladder treatment [for the case study project this was the situation, as none made use of the scope ladder provisions], an adjusted net present cost of the proponent?s submission is computed as follows: (this scoring provision is directed at long term user costs associated with service delivery; it is a surrogate for health care delivery costs, and is an attempt to link design features with client service delivery costs and outcomes); a) Calculate the number of points, including partial points, by which the points achieved by the proponent?s proposal exceed 30 points but do not exceed 80 points, multiplying the calculated number of points by $263,517 (the net present value of a point allocated by the Authority for this purpose) and subtracting the product from the net present cost of the proponent?s proposal ? i.e. [The adjusted net present cost = NPCa = NPC ? 263517*(min (score, 80) ? 30), and score must be greater than 30 to be compliant ? an implicit assumption in this 12  calculation is that the indicative design score is equal to 30 points. However, there is no calculation to confirm this. The total adjustment that can be earned is 263517 * 50 = $13.176 million, which is 10.3% of the affordability limit. While a significant number, a decision faced by proponents is whether or not to do a workmanlike job pursuing these points but focus on reducing capital and life cycle cost through a number of means, including use of one or more innovations, or seek to maximize the deduction to NPC through achieving a high heath delivery score]. 5. The proposal that offers the lowest NPC (net present cost) will be ranked the highest (NPV = NPC ? 263517*(min(score, 80) ? 30) + NPCenergy.)  A summary of the points available is provided in Table 1.2, along with a flagging of which items were considered in this study. This table is elaborated upon in Chapter 2.   For the purpose of this study, items with a low number of points assigned or score potential in relation to the total score possible for the criteria were not considered, the thought process being that proponents will focus on those criteria that have the greatest reward potential. However, an exception occurs for the enhance patient safety criterion class for items (c) standardization of rooms and (d ? i) Ability to safely monitor patients in pre-op/stage II recovery.  While both have a low score (4 and 2.5 points respectively), they relate directly to the form and layout of the building design and can be a significant differentiator amongst proposals. [The scoring of the proposal was provided. However, direct use was not made of these results ? they served as a useful reference when the research team believed there was either a significant difference in the proposals or none at all with respect to a specific criterion]. 13  Section in RFP Criteria Points  3.2.1.4 Enhanced patient safety  3.2.1.4 a. Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs).  15.5  considered 3.2.1.4 b. Travel efficiency measurement; patient transport routes (via elevators). 15.5 considered 3.2.1.4 c. Standardization of rooms, bays and support areas as : ? PARR; ? Pre-op and stage II recovery bays; and ? Non-OR Medication rooms. 4 not considered 3.2.1.4 d. i. Ability to safely monitor patients in Pre-op/stage II recovery. 2.5 not considered 3.2.1.4 d. ii. Ability to safely monitor patients in PARR. 6 considered 3.2.1.5 Optimize clinical utilization  3.2.1.5 a.  Location, orientation and access to medication rooms in Pre-Op/stage II recovery, CSICU and PARR 2 not considered 3.2.1.5 b. Location of storage spaces 3.5 considered 3.2.1.5 c. Separation and efficiency of flows: public, patients and materials. 16 considered 3.2.1.5.d. Workflow within medical device reprocessing (MDR). 5 considered 3.2.1.5 e. Workflow within medical device reprocessing (MDR). MDR process flow maps 6 not considered  3.2.1.6 Wellness environment  3.2.1.6 a. i. Access and quality of direct natural light for each room.                                                                    6 considered3.2.1.6 a. ii. Availability of borrowed and/or direct natural light as defined by the IHSC light measurement methodology document for each room  3.5 considered 3.2.1.6 a. iii. Access to outdoor space (exterior courtyard or roof garden) from staff lounges. 2.5 considered 3.2.1.6 b. and  3.2.1.6 c. Interior design features which provide natural and calming environments. 2.5 not considered 3.2.1.7 Enhanced site development features  3.2.1.7 a. i. Overall building exterior design 2.5  not considered 3.2.1.7 a. ii. Ease of access and way finding. 2 not considered 3.2.1.7 b. Site parking and vehicular flows will enable efficient and friendly access and egress to the site. 5 considered Total points  100  Table 1.2 Items to review in product view  14  Presented in Table 1.3 is a set of performance metrics used to characterize the proposals and indicative design from a product view perspective.  ? Compilation and validation of results: In Chapter 3, a comparison is made with the score sheet used by Partnerships BC, during the proposal review and evaluation process. The idea is to test the hypothesis that innovation drives differences in proposal scoring on a criterion by criterion basis. However, it is important to note that while innovation might be present, it does not necessarily lead to a superior score. 15    Metrics Units  Product view  2.3.1 Enhance patient safety  2.3.1.2.1 Travel distances for surgical staff to patients   Distance Pre Op to OR m  Distance PARR to Pre-Op m  Distance OR to staff lounge m  Number of staircases connecting levels 1 and 2  n  Floor location OR  Level  Floor location PARR Level  Floor location CSICU Level  Floor location staff lounge Level  Floor location Pre Op Level 2.3.1.2.2 Travel distances for patient transport from cardiac ORs m  OR to PARR m  Cardiac OR to CSIUC m  Pre-Op to OR m  Number of patient elevators n 2.3.1.2.3 Standardization of rooms, bays and support areas List of standardized elements 2.3.1.2.4 i) Ability to safely monitor patients in Pre-Op/stage II recovery  No of direct sight line  Number of team care stations n 16    Metrics Units  Number of care station under direct sight n 2.3.1.2.4 ii) Ability to safely monitor patients in PARR No of direct sight line  Number of private rooms n  Number of Isolation rooms n  Total number of rooms n 2.3.2 Optimize clinical utilization  2.3.2.2.1 Travel distances from OR, PARR and Pre Op to storage rooms m  OR to equipment m  OR to housekeeping m  OR to soiled utility m  PARR to clean utility m  Pre-Op to clean utility m 2.3.2.2.2 Number of storage rooms for each travel route   OR to equipment n  OR to housekeeping n  OR to soiled utility n  PARR to clean utility n  Pre-Op to clean utility n  Number of crossings (exceptions) n  Number of patient elevators n  Number of public elevator n  Number of logistics elevator n 2.3.2.2.3 Average distances from MDR  17    Metrics Units  Measurement 1 soiled elevator m  Measurement 2 soiled entry m  Measurement 3full case cart holding m  Measurement 4 sterile entry m 2.3.3 Wellness environment  2.3.3.2.1 Number of rooms with direct access to natural light    PARR n  CSIUC n  Pre-Op/stage II recovery bays n  Main staff n  MDR decontamination n  MDR clean zone n  MDR staff lounge n  MDR sterile zone n 2.3.3.2.2 Number of rooms with access to borrowed and/or direct light   PARR n  CSIUC n  Pre-Op/stage II recovery bays n  Main staff lounge n  MDR decontamination n  MDR clean zone n  MDR staff lounge n  MDR sterile zone n  CSICU team care station n  Surgery control center n  PARR team care station n 18    Metrics Units  Pre-Op team care station 1 n  Pre-Op team care station 2 n 2.3.4 Enhance site development features   Number of parking stalls  n Table 1.3 Product performance metrics19  1.5 Literature review  An extensive literature review was performed in terms of P3 procurement mode, innovation in P3 health care projects and case studies.  Most of the articles found were related to project delivery systems, in particular P3, and their advantages and disadvantages against traditional procurement modes, and P3 healthcare projects.  It was observed that no studies comparable to this thesis were found that examined different proposals for the same project.  1.5.1 Public private partnerships A P3 is a partnership between the government and the private sector, in which the private sector concessionaire builds and finances a facility and may also be contracted to provide facility management and maintenance services over a long term period (Siemiatycki and Farooqi 2012).  The ability to seek innovation all the way through the design and the use of new technologies during construction or operation is key to a P3 agreement. The integration of all project phases can reduce life cycle costs of facilities, which is not easily done with a non-integrated procurement system approach (Garvin 2004).  Despite the advantages of this type of procurement mode, P3s also have detractors. A paper by Ball, Heafey and King, (2000) on the U.K.?s private finance initiative (PFI) describes disadvantages of P3 in comparison to traditional procurement. They state that the bidding process in a private finance initiative is undoubtedly longer, complex and more expensive than 20  with traditional procurements methods. Moreover, the public sector has to make extensive use of external consultants for legal, technical, and financial advice. Ball et al. (2000) and conclude that the advantages of PFI are not as significant as it is believed. Further, according to McKee, Edwards, and Atun, (2006) the practical results for private financing of public facilities seem not to have lived up to what was expected from privately funded ventures. The new facilities have, in general, been more expensive than they would have been if procured using traditional methods, and while the processes involved in procuring standard hospitals are now well established, the complexity involved is increasing, especially for very large projects.   However, Russell, Tawiah, and de Zoysa (2006) note that P3 proponents contend that a number of disadvantages such as increasing costs of the bidding process and private sector financing can be balanced or outweighed by the benefits of widened involvement of the private sector. These benefits include greater efficiencies and economies achieved primarily through the implementation of innovation and greater discipline in controlling the budget and scope. These authors then go on to examine how the potential innovation of the private sector on infrastructure projects is a result of the procurement method selected. It also identifies factors or conditions that act as drivers or inhibitors of innovation for these types of projects.   The higher the levels of innovation in the construction industry, the greater the likelihood that it will increase its contribution to economic growth. Unfortunately, in most counties, there is a perception that the industry is not generally innovative, and that there is so much room for improvement (Blayse and Manley 2004).  21  Liddle (1997) analyzes the advantages of innovation from government infrastructure privatization (it is noted that use of a P3 arrangement is not privatization). He says there are two reasons for supporting privatization; private firms are more efficient (deliver project and service at a lower cost) and are more innovative for the design and operation phases. Innovations come from profit motive (more innovative designs and project solution), competition (constantly looking for ways to reduce costs and improve service) and economies of scale.  1.5.2 Innovation There is limited information and scientific research regarding the topic of innovation achieved on P3 projects, and in particular with respect to health care facilities. Of the articles found, most focused on general terms of innovation and not on drivers or inhibitors of innovation and the benefits derived.  According to Schumpeter (1961) innovation can be defined as an effort made by one or more individuals that produces an economic gain, either by reducing costs or by increasing income   The European Commission in the green paper on innovation report (European Commission 1995), defines innovation as a synonym for the successful production, assimilation and exploitation of novelty in the economic and social spheres.    22  Ling (2003) in his paper on management of innovation addresses the concept of risk as a key attribute in the definition of innovation. He extracted the key elements which would enable identification of a construction innovation, which are: newness (uniqueness of concept), first use within the industry, ability to affect change to standard practice, and derived benefits to all stakeholders and associated risks.  Slaughter (2000) says that a corporation must comprehend innovation and how it can be implemented and identifies five types of innovation: incremental (small development in a current practice); architectural innovation (small development within a specific area); modular innovation (major improvement or new concept within a specific region); system innovation (complementary innovations that work jointly to provide new functions); and radical innovation (completely new concept or approach).  According to Gambatese and Hallowell (2011), in its simplest form innovation is a positive change as a result of new ideas. While a false perception exists that innovation in the construction industry is lacking, decreasing cost and schedule duration, increasing productivity, safety and quality, or exceeding projected objectives often involve innovation. In the same work, the authors recognized the factors that have an effect on innovation in a project, as well as how those factors can be used to measure the level of innovation on a project, and the practices and processes that encourage and facilitate innovative changes. As a result, they established that innovation in the construction industry requires three components: idea generation, opportunity and diffusion. Applying the practices identified in their research leads to enhanced innovation through better communication amongst project team members, integration of the design and 23  construction disciplines, more efficient designs, development of unique ways of completing work and sharing of the lessons learned. The end result of innovation will be projects that successfully meet and exceed cost, quality, schedule and safety goals. The authors also recommend further investigation of project delivery and contracting methods in regard to their connection to innovation.  Leiringer (2006) claims that the use of output specifications and service level agreements enables private sector actors to be more innovative and use their skill and experience to create solutions that best serve the client?s needs. These claims follow the logic that private sector actors are given greater freedom to interpret the tender documents without being impeded by past practices, rigid standards and norms. The author concludes that it would be rash to claim that P3 is the panacea for change within the construction business. This is not the same as stating that there is no room for innovation on P3s but there are, as in other procurement modes, several potential inhibitors in the process that are likely to limit the amount of innovation achieved.  Following Leiringer, Barlow and K?berle-Gaiser (2008) discuss the private finance initiative and ask if it is generating innovative solutions (design innovation) for healthcare infrastructure. Their study focuses on hospitals built under PFI, currently the main procurement mode for this kind of project. PFI was endorsed by the U.K government as a means of introducing innovation into hospital delivery. They researched the relationship between the project delivery system used (the relationship between the funders, contractors and the public sector client) and design innovation in terms of physical adaptability (the ability of a building to economically accommodate future changing requirements). Design innovation has been a challenge in the healthcare projects, 24  where technologies, policies and services are subject to much shorter lifecycles than the relatively inflexible built assets that support them. Barlow and K?berle-Gaiser (2008) focused on case studies of PFI hospitals and shorter case studies of hospitals developed before the introduction of PFI. They found that the introduction of PFI has increased the complexity at the interface between project delivery and hospital operational functions and may have been less effective in stimulating design innovation and coping with future changes in demand than the model it replaced, which involved greater coordination across individual project and operational systems. But this is not to suggest that PFI or other variants are incapable of delivering innovation.  1.5.3 Factors allowing or hindering innovation  In this section is summarized a number of the factors that could drive (and in some cases possibly hinder) innovation. These factors are drawn from the work by Blayse and Manley (2004) and are: (1) client and manufacturers, (2) the structure of production; (3) industry relationships; (4) procurement systems; (5) regulations/standards; and (6) the nature and quality of organizational resources. Factors 1, 3, 4 and 5 are briefly elaborated upon the context of the IHSC project.  (1) Client and manufacturers The client, the Health Authority and particularly the agent Partnerships BC, as learning organizations have extensive previous experience with the procurement of health care projects, especially using a P3 procurement mode. This experience was brought to bear through a rigorous procurement process in which there was significant clarity of the 25  client?s value systems in terms of a scoring system.  This clarity was achieved through specifications which conveyed clients needs, substantial preparatory work in the form of an indicative design, etc. In summary there was a seasoned and knowledgeable client which helped to install confidence in proponents as to what was required, allowing proponents to focus on delivering very comprehensive project solutions. Selecting a procurement mode that encourages competitors provides a driver for innovation. This encouragement, however, is tempered by the clients desire to transfer more risk to the private sector. (3) Industry relationships Given the flow of work, especially in the health sector in B.C. as well as Ontario, some of the proponent teams have prior experience working together as well as interacting with Partnerships BC. This experience gained from learning together both at the individual level as well as the firm level helps to install trust, and allows a more intense focus on developing a winning proposal. This is further enhanced by the knowledge that there is a substantial deal flow of similar projects in the years ahead. (4) Procurement systems The selection of a full-fledged P3 procurement mode (DBFM) further enhances the drivers for innovation, tempered as stated previously by the client?s desire to transfer more risk to the private sector partner. P3 procurement drives innovation in a number of ways, but three central elements are the incorporation of a design competition into the process, the provision of an indicative design which provides a target to beat, and an emphasis on life cycle performance, which forces the need for tradeoffs between capital 26  and operational costs. Added to this is the incorporation of a client scoring system that reflects long term client service delivery costs. (5) Regulations/standards Treated briefly here is the emergence of guidelines of good design practice for health care facilities, ongoing research and related findings as to the relationships between building design and client service delivery costs, and wellness or health care outcomes. Client awareness of such guidelines and research, as reflected in the project?s RFP and evaluation system help drive more creative solutions including foreign proponents to enhance their knowledge and awareness of practices on an international basis.  1.5.4 Experience in P3 health care projects in Australia, U.K and Canada Several cases were reviewed regarding experience in the execution of P3 health care projects around the world. According to Taylor (2002), public hospitals worldwide are facing a financial crisis, mainly because of rising costs and public budget constraints. P3 offers the potential for innovative ways to control costs and improve service. As observed earlier, such partnerships are seen mainly in countries with national health services, like Australia, the U.K. and Canada. Each country makes use of different procurements modes, Australia being the country with the most diverse ranges of modes. Modes used include: BOO (in which a private company builds, owns, and operates the facility); conversions (in which a hospital is sold to a private operator); private management of public hospitals that the government continues to own; build-own-leaseback arrangements (in which a private firm constructs a new public hospital, then leases it back to the government); and, collocations (in which a private wing is located within or beside a public 27  hospital). These initiatives were driven by a need for new capital, a perceived need to transfer operational risk, and a desire to increase efficiency.  The private finance initiative (PFI) for public hospitals has been used over the last 20 years in the U.K. as a strategy for improving and modernizing public services (Wall and Connolly 2009). The charge to the public sector includes the capital cost and a charge for the service, with the resulting ?unitary payment? charged over the life of the contract which may extend beyond 20 years. PFI is thought to have advantages over traditional procurement, including risk transfer innovation and value for money (Ball et al. 2000).  P3 for the healthcare sector is the most active in Canada according to the Canadian Council for Public-Private Partnerships. The model chosen for these projects is design-build-finance-maintain (DBFM). The ?Picture of Health? document of December 2002 encourage health authorities to investigate P3 and use it to bring VfM and more importantly improve patient care like the Canada Health Act establishes (Partnerships British Columbia 2005). As of 2013, there are 71 of those projects in Canada.  Described in Table 1.4 are some of the benefits described in the value for money reports for some health care projects in BC procured using P3. The projects mentioned are: Royal Jubilee Hospital Patient Care Centre, Surrey Outpatient Hospital, Abbotsford Regional Hospital and Cancer Centre project and Interior Heart and Surgical Centre. The rest of the list is presented in Melej (2013). 28  Many of these benefits/innovations claimed in Table 1.4 would exist in any health care project, irrespective of procurement mode used. Indeed, a challenge faced in evaluating the efficacy of a particular procurement mode is being able to distinguish between benefits that can be ascribed to the project versus the incremental benefits brought by choice of procurement method. Interestingly, in terms of the benefits/innovations associated with these projects, few truly innovative features stand out.  The usefulness of these value for money reports lies mainly in their provision of relevant project information and transparency regarding the procurement mode chosen for the facility. Comparable reports for traditional project delivery are basically non-existent.   29  Project name Project agreement Value for money Expected benefits and innovation Royal Jubilee Hospital Patient Care Centre. (Partnerships British Columbia 2008b) ? Design, build, finance and maintain. ? Project capital cost: $282.5 million (only DBFM contract) ? Operating Term: 30 years The final agreement was expected to achieve value for money of $22.2 compared to a traditional procurement mode ? The design was informed by evidence based literature, and in particular the resources of the Center for Health Design in the U.S ? First Canadian project to be recognized by the center for health design as a PEBBLE3 partner, with access to leading design and research support, as well as access to international experts in the field ? The design incorporates a wide range of elder friendly attributes. ? Large opening windows that maximize natural light and views to the outside. ? Large percentage of single-bed rooms, which is expected to reduce hospital acquired infection rates. ? Rooms have been designed to allow family members to participate in patient care. ? Easy to navigate, clear hallways. Logical and intuitive flow for the layout of the building. ? Creation of acuity adaptable rooms to reduce the need to move patients from one clinical setting to another  ? Outstanding patient monitoring capability. ? Logical and intuitive flow for the layout of the building. ? Air exchange system allows for isolation at the room, pod, unit, ward/floor level in the case of infectious disease outbreak requiring isolation.  ? A magnetic work place that attracts retains and                                                  3 The purpose of PEBBLE partnership is to provide researched and documented examples of health care facilities whose design makes a difference in the quality of care provided 30  Project name Project agreement Value for money Expected benefits and innovation trains high quality staff. ? A sustainable solution that will have a light footprint on the ecosystem through the build, operate and maintain phases ? The facility will be designed and built to a LEED gold standard  Surrey Outpatient Hospital. (Partnerships British Columbia 2009)        ? Design, build, finance and maintain. ? Project capital cost: $172,4 million(only DBFM contract ? Operating Term: 30 years The final agreement was expected to achieve value for money of $22,5 compared to a traditional procurement mode ? A more patient-centered, modern express service concept ? Efficient patient flows through the facility, with intuitive way-finding to help patients access their health services. ? Convenient access and parking, opportunity for electronic patient registration, as well as pharmacy and retail outlets and access to outdoor space. ? Flexibility for the future, including modular/moveable walls, wireless information technology (IT) capability, and mechanical capacity to allow for facility expansion ? An innovative approach to pipes and ducts(located on the exterior of the building to provide internal space flexibility) ? An environmental friendly, energy efficient building design to achieve LEED gold certification.        31  Project name Project agreement Value for money Expected benefits and innovation Abbotsford Regional Hospital and Cancer Centre project. (Partnerships British Columbia 2005)  ? Design, build, finance and maintain. ? Project capital cost: $355 million ? Operating Term: 30 years The final agreement was expected to achieve value for money of $39 million compared to a traditional procurement mode ? A preliminary design that meets or exceeds requirements for clinical functionality, operational efficiency and design objectives ? Site utilization that maximizes the preservation of natural features allowing future expansions ? A design that includes the flexibility to adapt to future health Authority needs and is capable of horizontal and vertical expansion. ?  Design that is aesthetically pleasing, creating a healing environment. ? A design that is planned to meet LEED silver standards. ? Access to outdoors for patients, families and staff through a series of indoor and outdoor courtyards and a roof deck. Interior Heart and Surgical Centre. (Partnerships British Columbia 2012).  ? Design, build, finance and maintain. ? Project capital cost: $169.1 million ? Operating term: 33 years The final agreement was expected to achieve value for money of $33.4 million compared to a traditional procurement mode ? Reduced overall cost and shortened construction schedule by anticipated four floors to accommodate the programmed space. ? Enhanced operational efficiencies (standardization in 60 of 62 rooms) ? Improved healing environment for patients and better working environment for staff ? Better opportunity for staff to relax and rejuvenate during breaks ? More efficient operations and a convenient environment for patients and their families. ? New facilities available to IHSC patients 13 months earlier than anticipated. Table 1.4 Summary of benefits and innovations identified in value for money reports produced by Partnerships BC for health care projects32  1.6 Project overview  As mentioned previously, this study is focused on developing and applying a method that assists with identifying innovation included in the proposals submitted by the three consortiums invited to present their solutions as a response to the RFP issued by Partnerships BC for the Interior Heart and Surgical Centre building (IHSC) project in Kelowna, BC (See Figure 1.2).   Figure 1.2 Project site plan   The actual Interior Heart and Surgical Centre building (IHSC) will be a three-storey building that incorporates a cardiac and inpatient surgical suite, cardiac surgery intensive care unit, pre- and post-operative care unit, and the new medical device reprocessing department. The building was designed to allow future expansion to accommodate approximately 32 medical/surgical inpatient N 33  beds on a fourth floor (RFP requirement).The IHSC building will be designed and built to achieve leadership in energy and environmental design (LEED gold certification).  With the purpose of achieving the best potential value for money for the project, Partnerships BC made a careful examination of procurement options. According to The Interior Heart and Surgical Centre value for money report (Partnerships British Columbia 2012) the choice was to use the DBFM delivery method. Firstly, they identified the procurement goals and the two most suitable procurement modes for this project. The second step in the assessment involved a quantitative analysis, including risk analysis and representation of financial models to compare the two methods, design-bid-build (DBB) and design-build-finance-maintain (DBFM). DBFM was expected to result in a lower cost for the project and better overall benefits compared to the DBB delivery method.   The form and site of the project was restricted by geotechnical constraints and corrective work was required to hold the weight of a new building. In addition, the weight of the new building would affect the integrity of the existing buildings. All this information was considered in the indicative design.  Another of the challenges related to the design was to create a floor plate large enough to accommodate the required functions of a surgical centre. Specific functions related to the operating rooms, such as PARR and CSICU, must be located on the surgical floor along with the operating suites.  34  Considering all the requirements and constraints, the IHSC building proposal evaluation team used an evaluation methodology to rank the proposals submitted by the three proponents. The methodology is explained in the Heart and Surgical Centre value for money report (Partnerships British Columbia 2012) and included scored criteria based on the achievement of measurable operating outcomes as defined by the Health Authority.  As indicated in the RFP the net present cost of the project must not exceed $128.17 and according to the value for money analysis, an expected saving of $33 million would be achieved with a P3 procurement mode compared to the traditional procurement mode.  The winning proponent signed an agreement to design, build, finance, and maintain the IHSC building for a term of 33 years (including the construction period). Their geotechnical solution reduced the construction schedule 13 months.    35  1.7 Contribution to the work Contributions of this thesis include: ? Insights about the studies and research carried out to date on the topic of innovation in the construction industry; ? A methodology that helps to identify innovation throughout a proposal analysis focused on the product perspective; ? Demonstration of the proposition that a P3 procurement method results in innovation through use of an integrated model of project delivery and operation and a competitive process that treats design, construction and facilities management services; and, ? Partial demonstration that there may be a relationship between innovation and score. However, it is important to note that while innovation might be present, it does not necessarily lead to a superior score.   No comparable research was found in the literature for any part of the world. Hence the findings are grounded in the reality of an actual project.   36  1.8 Thesis structure This thesis is structured as follows: Chapter 1 Thesis overview: Presented in this chapter is the motivation and background for the research, objectives, methodology, literature review and project overview.   Chapter 2: Assessing innovation: Examined in this chapter is the extent of innovation presented in each proposal presented by the three proponents invited to participate in the bidding process for the financing, design, construction, operation and maintenance of the Interior Heart and Surgical Center. The focus was to find and assess innovation on the product view of the three proposals submitted. This chapter presents the information (facts) included in the proposals, as well as the information included in the RFP.  Chapter 3 Conclusions: This chapter summarizes the findings from Chapter 2. No consideration was given to any innovations used in the financing of the project. The chapter concludes with suggestions for further work related to this research area. For completeness  of the performance metrics relative to assessing innovation, refer to Melej (2013) who focused on the process perspective of the IHSC project.  37  Chapter  2: Assessment of innovation through indicative design and proposal characterization  In order to assess an innovation and in some way measure the cleverness/innovativeness/novelty of the ideas proposed by each proponent, specific items were chosen to be studied and evaluated, as described in Table 2.1. Product view 3.2.1.4 Enhance patient safety (SI) 3.2.1.5 Optimize clinical utilization (SI) 3.2.1.6 Wellness environment (SI) 3.2.1.7 Enhanced site development features (SI) Table 2.1 Product view  This chapter presents the information (facts) included in the proposals submitted for the IHSC project, as well as the information included in the RFP. This proponent information allows a comparison to be performed between the indicative design and proposals submitted. Descriptive information extracted directly from a proposal is shown in italics but without quotation marks.  According to the definition of innovation stated before, innovation would be identified as differences amongst the indicative design and the three proposals.  38  With the purpose of keeping confidentiality of the information used for this study, the name and order of the consortiums that participated and presented their proposals for the IHSC project will be identified only as proponents 1, 2 and 3.   2.1 Indicative design  As part of the RFP process, the indicative design is available to all proponents along with the following summary information pertaining to it (it is important to note that the indicative design achieved or exceeded the minimum requirements):  ? Anticipate four floors to accommodate the programmed space. ? Require a minimum of 51 out of 62 standardized rooms. ? Achieve direct natural light in four of the CSICU rooms, half of the 22 Pre-Op/stage II recovery bays, and none of the PARR bays. ? Serve as a baseline for the scored criteria. ? Requires 47 month construction period.  Figures A1 to A6 from Appendix A show the layout of the indicative design included in the RFP.  Figure 2.1 shows the building elevations. The allocation of functions to levels is as follows: ? Level 1 - cardiac surgical room (CSR). ? Level 2 ? PARR, OR and CSICU. ? Level 3 ? Surgical support and staff facilities. ? Level 4 ? Mechanical floor. ? Level 5 ? Future expansion. 39                     Figure 2.1 Indicative design building elevations N/E/S/W faces 40  Shown in Table 2.2 are the distances between different locations among the IHSC building as extracted from the IHSC travel efficiency distance analysis for the indicative design. To assist in identifying innovations amongst the proponent designs and in relationship to the indicative design, especially with respect to layout issues, this information will be compared with the distances proposed by each proponent.  Independent checks to corroborate the values for all distance metrics as reported by the proponents themselves were not conducted in this work.  Definitions of efficiency measures as presented in the RFP are shown in Table 2.2. Figure 2.2 provides relevant formula to assist with efficiency measure calculation and interpretation.  A larger average corridor efficiency number is better since it means a more direct path between 2 points (straight path =100% efficient). A smaller travel efficiency distance suggests the travel distance is shorter and more direct.   41  From To Average corridor efficiency Average actual distance Travel efficiency distance OR's Staff lounge 77.3% 84.34 103.49 OR's Equipment storage 76.9% 34.03 41.90 CSICU Clean utility 70.5% 11.26 14.58 Pre-Op bays Clean utility 69.8% 27.83 36.23 Cardias OR's CSICU pat. Rms. 69.3% 40.43 52.84 Clean elevator OR's 68.9% 32.88 43.10 PARR bays Clean  utility 68.5% 16.29 21.43 OR's Housekeeping 68.4% 46.80 61.59 OR's PARR 64.1% 70.10 95.26 PARR bays Pre-Op bays 62.2% 103.25 142.28 Pre-Op bays OR's 59.8% 119.19 167.10 OR's Soiled utility 52.6% 63.93 94.24 OR's Pre-Op bays 76.0% 115.80 143.54 PARR bays Pre-Op bays 79.8% 92.08 110.68 Table 2.2 Indicative design measurements (m)   Figure 2.2 Relative corridor efficiency and travel efficiency distance formulas  Using the metrics in Table 2.3 presented previously in Chapter 1, a characterization of the IHSC is made in order to help with the comparison between the indicative design and each proponent proposal.  42    Metrics Units  Product view  2.3.1 Enhance patient safety  2.3.1.2.1 Travel distances for surgical staff to patients   Distance Pre Op to OR m  Distance PARR to Pre-Op m  Distance OR to staff lounge m  Number of staircases connecting levels 1 and 2  n  Floor location OR  level  Floor location PARR level  Floor location CSICU level  Floor location staff lounge level  Floor location Pre Op level 2.3.1.2.2 Travel distances for patient transport from cardiac ORs m  OR to PARR m  Cardiac OR to CSIUC m  Pre-Op to OR m 43    Metrics Units  Number of patient elevators n 2.3.1.2.3 Standardization of rooms, bays and support areas List of standardized elements 2.3.1.2.4 i) Ability to safely monitor patients in Pre-Op/stage II recovery  No of direct sight line  Number of team care stations n  Number of care station under direct sight n 2.3.1.2.4 ii) Ability to safely monitor patients in PARR No of direct sight line  Number of private rooms n  Number of Isolation rooms n  Total number of rooms n 2.3.2 Optimize clinical utilization  2.3.2.2.1 Travel distances from OR, PARR and Pre Op to storage rooms m  OR to equipment m  OR to housekeeping m  OR to soiled utility m  PARR to clean utility m  Pre-Op to clean utility m 2.3.2.2.2 Number of storage rooms for each travel route  44    Metrics Units  OR to equipment n  OR to housekeeping n  OR to soiled utility n  PARR to clean utility n  Pre-Op to clean utility n  Number of crossings (exceptions) n  Number of patient elevators n  Number of public elevator n  Number of logistics elevator n 2.3.2.2.3 Average distances from MDR   Measurement 1 soiled elevator m  Measurement 2 soiled entry m  Measurement 3full case cart holding m  Measurement 4 sterile entry m 2.3.3 Wellness environment  2.3.3.2.1 Number of rooms with direct access to natural light   45    Metrics Units  PARR n  CSIUC n  Pre-Op/stage II recovery bays n  Main staff n  MDR decontamination n  MDR clean zone n  MDR staff lounge n  MDR sterile zone n 2.3.3.2.2 Number of rooms with access to borrowed and/or direct light   PARR n  CSIUC n  Pre-Op/Stage II recovery bays n  Main staff lounge n  MDR decontamination n  MDR clean zone n  MDR staff lounge n 46    Metrics Units  MDR sterile zone n  CSICU team care station n  Surgery control center n  PARR team care station n  Pre-Op team care station 1 n  Pre-Op team care station 2 n 2.3.4 Enhance site development features   Number of parking stalls  n Table 2.3 Product view performance metrics47  2.2 Description of proponents proposals 2.2.1 Proponent 1 Proponent 1 solution reduces from 5 levels (indicative design) to 4. The last floor would have the mechanical penthouse and space for future expansion.  The allocation of functions to levels is as follows ? Level 1 - Pre-Op /level II recovery department, exterior courtyard;  ? Level 2 - CSICU, PARR, operating rooms; and, ? Level 3 ? MDR and mechanical services. ? Level 4 ? Future expansion and mechanical penthouse.  Proponent 1 indicates that the OR?s are designed on a ?race track? principle with the sterile core in the centre of the track for easy and direct access from the sterile core into each OR. The location of the reception desk and waiting area for the Pre-Op department is central to the 46 bed department minimizing travel distances to each of the Pre-Op bays, and the patient elevators are central to the Pre-Op.  Access for the public to the 2nd floor CSICU is designed so that they exit from the elevators into a restricted waiting area which has controlled access into the patient zone. This access area is completely separated from the staff corridor linking Strathcona with Centennial building.    48    Figure 2.3 Proponent 1 building elevations N/E/S/W faces 49  2.2.2 Proponent 2 Proponent 2 reduces the overall building by one floor from that shown in the indicative design. The reduction in building levels has been accomplished by locating the building mechanical services space on part of level 4, and leaving space for the proposed future 32-bed inpatient unit (IPU) on the same level. The allocation of functions to levels is as follows ? Level 1 - Pre-Op and the administrative and staff facilities;  ? Level 2 - CSICU, PARR, operating rooms; and, ? Level 3 ? MDR.  There are a total of 8 elevators and 5 stairwells in the IHSC Building design. Proponent 2 indicates that in general, the elevators have been centrally located for the movement of patients, staff, the public and materials. The stairwells are restricted/egress only and have been positioned to minimize staff travel distances between departments.  Two connections have been provided at level 1 to extend existing corridors from the Strathcona building. A public corridor to the north allows all building users to circulate to and from the Strathcona building, and a corridor to the south provides a direct, restricted logistics connection between the Strathcona service areas and the IHSC patient/service elevators.      50    Figure 2.4 Proponent 2 building elevations N/E/S/W 51  2.2.3 Proponent 3 Proponent 3 reduces the overall building by one floor from that shown in the indicative design. The building elevations are shown in Figure 2.5. The reduction in building levels has been accomplished by locating the MDR and the building mechanical services space on level 3 and leaving level 4 for the future inpatient unit.  The allocation of functions to building levels is: ? Level 1 - Public circulation/material support level and emergency, imaging services;  ? Level 2 - Cardiac CSICU, surgery, ICU, interventional medicine; and, ? Level 3 - MDR, day surgery, maternity/birthing suite.   52    Figure 2.5 Proponent 3 building elevations N/E/S/W 53  2.3 Proposal analysis In this section, the responsiveness of the proponent proposals and indicative design to the RFP scoring related to various dimensions of service delivery are examined. It is observed that comparable data is not always present ? notably less information is available with respect to some performance dimensions for proponent 3 and the indicative design.  2.3.1 Enhance patient safety (RFP 3.2.1.4) This item relates with the objective of enhancing efficiencies and achieving optimal patient safety in order to reduce adverse events by reducing patient transport routes and maximizing logistical space planning. The operating environmental design is relevant since an efficient layout can reduce the potential for medical and surgical errors. According to the RFP, the circumstances surrounding medical and surgical errors vary considerably but there are predictable indicators of how and when they are most likely to occur. Regarding this issue the RFP specifies the following considerations: ? Staffs feel rushed or distracted: Solutions include making ease of access to patients via vertical and horizontal routes as quick and convenient as possible and reducing overall staff travel distances through an efficient arrangement of a program?s functional components. ? Non Standardized Rooms: Working in unfamiliar rooms may require extra concentration. Solutions include standardization strategies that reduce the reliance on short-term memory or allow staff to work within a space more efficiently by laying out a space in the same way for each occurrence.  54  ? The standardization of spaces and room design, from the location of the outlets, to bed controls, to the location of latex gloves, all have an impact on human behavior and patient risk. ? Provide clear sightlines to decentralized care stations and patient beds. Sightlines allow staff to monitor patients and to support other staff members without leaving the care stations or abandoning a task. ? Provide appropriate task lighting to reduce medication-related errors in medication rooms, to allow staff to read labels and prescriptions more easily. In areas such as care stations, staff should be able to adjust the lighting levels in their work space. Provide the ability to modify lighting levels in patient rooms to accommodate both patient and staff needs during different times of the day. ? The medication rooms shall be centrally located and convenient for quick staff access. All medication rooms are to be fully enclosed unless otherwise directed by the Authority. However, there are instances where key patient site lines may be blocked by full height walls. This may occur in the PARR and CSICU departments. ? Maintain a direct line of sight from the team care station to centrally located medication rooms in these two departments through the use of large windows and automatic sliding glass doors into the medication rooms.  The RFP specifically requests each proponent to deliver the following information in terms of enhancing patient safety. This item is evaluated by Partnerships BC according to specific criteria.    55  In terms of earning scoring points, set out in the RFP are minimum and maximum distances, between which proponents are ?encouraged? to find a design solution. For purposes of evaluation in this thesis, the assumption is made of a linear relationship between score and distances, as shown in Figure 2.6.  For travel distances that are superior to the minimum distances no incremental points can be earned. If the design distances are greater than the maximum prescribed, negative score are not assigned. Seemingly, if a design distance is less than the minimum or greater than the maximum, the design still deemed to be compliant. It is not known if a simple linear function was applied for the proposal evaluation team.         Figure 2.6 Linear relationship score/distance    Maximum score Minimum score Maximum score distance Minimum score distance Distance Score 56  2.3.1.1 Enhance patient safety ? requirements 2.3.1.1.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs). (RFP 3.2.1.4 a).  Criterion: Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs).   Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the criteria indicated below. The minimum score is 0 points and maximum for this criteria is 15.5 points.   As explained previously, a smaller number suggests the travel distance is shorter and more direct, and thus attracts a higher score. Elements Travel efficiency distance Travel route Available points Minimum score  distance Maximum score distance Pre-Op to OR 6 167.1 m 145.5 m PARR to Pre-OP 6 110.68 m 120.8 m OR to staff lounge 3.5 103.5 m 93.1 m Table 2.4 Travel distances for surgical staff to patient   57  Travel efficiency distance is calculated as follows: Travel efficiency distance = (1 - Corridor efficiency) x (actual path of travel) + Actual travel distance Corridor efficiency is calculated as follows: ? Corridor efficiency = Direct A to B distance measurement(green line)/ Actual design A to B distance measurement(red line)   Figure 2.7 Travel efficiency distances    58  2.3.1.1.2 Travel efficiency measurement; patient transport routes (via elevators) (RFP 3.2.1.4 b) Criterion: Travel efficiency measurement; patient transport routes (via elevators).  Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the criteria indicated below. The minimum score is 0 points and maximum for this criteria is 15.5 points. A smaller number suggest the travel distance is shorter and more direct, that is the reason that the minimum score is given to a larger distance. Elements Travel efficiency distance Travel route Available points Minimum score  distance Maximum score distance OR to PARR 6 95.2 m 80.8 m Cardiac OR to CSICU 6 52.8 m 48.3 m Pre-Op to OR 3.5 167.1 m 145.3 m Table 2.5 Travel distances for patient transport from cardiac Ors  2.3.1.1.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms (RFP 3.2.1.4 c) Criterion: standardization of rooms, bays and support areas.  Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the criteria indicated below. The minimum score is 0 points, which means 6 deviations or more and maximum of 4 point which means 0 deviations. 59  Examples of deviations:  ? Outlets not standardized in quantity or location; ? Light switches not standardized in quantity or location; ? Millwork not standardized; ? Patient orientation not standardized; ? Patient lift not standardized;  ? Interior finishes not standardized; ? Headwall design not standardized;  ? Equipment placement not standardized.  2.3.1.1.4 Ability to safely monitor patients in the following areas (RFP 3.2.1.4 d) I. Ability to safely monitor patients in Pre-Op/stage II recovery  Criterion: The direct sight line from a total of 3 locations in Pre-Op/stage II recovery. The direct sight re measure from the team care station (unit clerk in seated position), location to all of the 22 decentralized care stations.  Evaluation criteria: In order to evaluate and compare the proposals, the evaluating team used the following criteria: The minimum score is 0 points, which means that the team care station views a total of 11 decentralized care stations, while a maximum score of 2.5 points means that team care station views a total of 22 decentralized care stations.   60  II.  Ability to safely monitor patients in PARR. Criterion: The direct sight line from the main care station (Unit clerk in seated position, from a total of 2 locations within the main care station) to the head of the patient on each of the 20 stretchers in PARR and the entry into the 2 isolation ante rooms.   Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the following criteria. The minimum score is 0 points if 18 bays are seen from the unit clerk location. And a maximum of 6 points if 20 bays and the entries into 2 isolation ante are viewed.  2.3.1.2 Enhance patient safety - assessment of innovation After having identified and characterized each proponent regarding the item ?enhance patient safety?, it is possible to compare each of the solution proposed against the indicative design and judge, when it is possible, if innovation is the reason of those differences.  For these criteria, proponent 3 did not tabulate the information in its proposal. The purpose of this study was not to corroborate the distances, thus some values for proponent 3 are not compared to the indicative design.  2.3.1.2.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs).  As shown in Figures B1, B2 and B3 from Appendix B, proponent 1 offers a single stairwell located on the east edge connecting the Pre-Op to the OR. According to this configuration the longest travel route from Pre-Op to OR is 134.7 m, PARR to Pre-Op is 87.07 m and OR to staff lounge is 69 m. All distances are shorter than the maximum distance specified in the RFP. 61  Proponent 2 offers a different configuration, where the staff travelling from the Pre-Op department on Level 1 to the OR on level 2 can use 3 different stairwells, all restricted to staff only. As seen in Figures B4 to B9, one stairwell is centrally located and two others are located on the east side. According to this configuration the longest travel route from Pre-Op to OR is 105.52 m, PARR to Pre-Op is 101.45 m and OR to staff lounge is 72.87m, satisfying the staff travel distance required. Finally, the solution given by proponent 3, as shown in Figures B10 to B15 involves three stairwells for staff use only: one stairwell connects the Pre-Op at level one to OR at level two; the second stairwell on the north side connects the Pre-op to PARR; and, the third stairwell connects the staff lounge on level one to the OR on level 2. With this, proponent 3 meets the travel distances required.  Comparing the three proponents with the indicative design Figures A1 to A6, and the maximum travel distance requirements indicated in RFP, it is possible to conclude that all proponents comply with the requirements.   In terms of assessing innovation, in this point shorter travel distances are considered positive factors; therefore it is possible to conclude that proponents 1 and 2 present solutions that are substantively superior to the indicative design and thus one can reasonably conclude that the solutions offered are more clever or innovative. Table 2.6 shows a comparison between the indicative design and the three proponents in terms of travel distances for the surgical staff to patients.  62  A weighted score (simple linear interpolation of the score) is computed in order to find significant differences in score. For this specific case, all proponents indicate shorter distances that indicative design, thus all obtained the highest score available (15.5 points). In this case the ranking obtained by interpolation coincides with the one indicated in the evaluation report which assigned the maximum score available to each proponent. The reason is that although they offer different layout, all of them are compliant and exceed the indicative design and the scoring system does not give more points even if the minimum requirements are exceeded (actual distances are shorter than the best distance in the requirements).     Travel efficiency distances     Available points Minimum score distance Maximum score distance Proponent 1 Proponent 2 Proponent 3 Distance Pre Op to OR 6 167.1 m 145.5 m 134.71 105.52 Not available Distance PARR to Pre-Op 6 110.68 m 120.8 m 87.07 101.45 Not available Distance OR to staff lounge 3.5 103.5 m 93.2 m 69.08 72.87 Not available Number of Stairs connecting level 1 and 2    1 3 3 Floor location OR    2 2 2 Floor location PARR    2 2 2 Floor location CSICU    2 2 2 Floor location Staff Lounge    1 1 1 Floor location Pre Op    1,2 1 1 Score by interpolation 15.5   15.5 15.5 Info not available Table 2.6 Travel distance summary surgical staff to patient 63  2.3.1.2.2 Travel efficiency measurement; patient transport routes (via elevators) According to proponent 1 lay out, the OR and CSICU rooms are on the same level, and in a direct line with three turns, the maximum distance is 39.9 m.(see Figure B16) and the distance between Pre-Op to OR is 103.8 m.(Figure B17). In terms of the distance between the OR and PARR, the travel distance is 92.9m (Figure B18), being close to the maximum distance allowed. For proponent 2, the access from the operation rooms to PARR is given by two non public entrance routes located in same level (Figure B19) with a distance of 92.1 m. For the cardiac OR to the CSICU (Figure B20) the travel distance is 46.7 m and the distance between the Pre-Op to OR is 164.2 m (Figure B21 and B22). This distance is also close to the maximum travel distance permitted. For proponent 3, the layout is shown in Figure B10 to B15. According to the information available, is not possible to determine the exact distances. However, analyzing the drawing it is reasonable to say that some distances are less than the maximum allowed.   Comparing the three proponents with the indicative design, all layouts are different. In terms of a clever layout it is possible to say that proponent 1 presents the shortest distances compared to the indicative design.   For this item, is also possible to compute a weighted score in order to obtain a relative ranking for the proposals. By computing a linear interpolation of the results, it is possible to observe that proponent 1 obtained the highest weighted score followed by proponent 2. This ranking (obtained by interpolation) coincides with the ranking indicated in the evaluation report developed by Partnerships BC.    64    Travel efficiency distances     Available points Minimum score Maximum score Proponent 1 Proponent 2 Proponent 3 OR to PARR 6 95.2 m 80.8 m 92.93 m 92.11 m Info not available Cardiac OR to CSIUC 6 52.8 m 48.3 m 39.91 m 46.72 m Info not available Pre-Op to OR 3.5 167.1 m 145.3 m 103.83 m 164.2 m Info not available Number of patient elevators    2 3 3 Weighted score (Interpolation) 15.5   10.45 7.75 Info not available Table 2.7 Travel distance summary patient transport routes  2.3.1.2.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms (3.2.1.4 c) RFP) Table 2.8 provides a detailed overview of the extent of standardization of rooms for each proposal. From the table, it is possible to conclude that all proponents meet the standardization requirements for the rooms indicated in the RFP. However, in terms of assessing innovation it is not possible to determine if innovative ideas were proposed, since the RFP only asks to meet specific requirements and does not present specific design for this topic.  For this item, the evaluation report shows that all three proponents obtained similar scores; with proponent 3 getting the maximum score. 65  Rooms Proponent 1 Proponent 2 Proponent 3 CSICU ? Breakaway sliding glass doors, u-shaped staff work zone around head of patient and extends down conjoining wall between patient rooms; ? Booms are suspended from a single pivot point at the patient head to serve both sides of the bed; ? The handwashing sink is next to the connecting door between patient rooms ? Electrical switches and outlets are standardized and placement is the same in each room. ? Interior finishes are standardized; ? casework is standardized and placement is the same in each room ? Doors ? Work zones ? Decentralized care centers ? Medical equipment (patient bed booms) ? Plumbing fixtures ? Electrical switches (light switch, outlet locations) ? Interior finishes ? Case work ? Doors ? Work zones ? Decentralized care centers ? Medical equipment (patient bed booms) ? Plumbing fixtures ? Electrical switches (light switches, outlet locations) ? Interior finishes ? Case work ? Gases ? Bumper rails, ? Light fixtures and switches ? Power/data PARR ? Bay access is from the foot of patient stretcher; ? Head wall is located below window, is across or behind the back wall in the patient bay and wraps down ? visitor side of the bay and does not interfere with headwall standardization; ? Minimum length = 3380mm ? Minimum width = 2925mm ? Electrical switches and outlets are standardized and placement is the ? Bay access ? minimum opening, ? Medical equipment (bed orientation) ? Impact of structure (windows, columns) on standard headwalls  ? Minimum length ? Minimum width ? Electrical (lighting and outlet location)  ? Ceiling heights  ? Plumbing fixtures ? Bay access ? Medical equipment (bed orientation) ? Impact of structure (windows, columns) on standardization of headwalls ? Minimum length ? Minimum width ? Electrical (outlets: quantity and location, light switches: quantity and location, light fixture location) ? Ceiling heights ? Patient lift 66  Rooms Proponent 1 Proponent 2 Proponent 3 same in each bay; and ? Ceiling height = 2800 mm ? Interior finishes ? Headwall design - wall protection, gases, bumper rails, fixed equipment, monitor, light fixtures and ? switch location, data/power ? Bed controls ? Glove dispensers ? Privacy curtain Pre/Post Op ? Bay access, minimum opening = 1550mm ?  Patient stretcher orientation is standardized in each bay; ?  Head wall is standardized and located on back wall; ?  Minimum length = 3285mm ?  Minimum width = 2595mm ?  Electrical switches and outlets are standardized and placement is the same in each bay; and ?  Ceiling height = 2800 mm ?  Hand washing sink is located on patient?s right  ?  Bay access ? minimum opening, ?  Medical equipment (bed orientation) ?  Impact of structure (windows, columns) on standard headwalls  ?  Minimum length ?  Minimum width ?  Electrical (lighting and outlet location)  ?  Ceiling heights  ? Plumbing fixtures ? Bay access ? minimum opening ?  Medical equipment (bed orientation) ?  Impact of structure (windows, columns) on standard headwalls ?  Minimum length ?  Minimum width ?  Electrical (outlets: quantity and location, light switches: quantity and location, light fixture location) ? Ceiling heights ?  Plumbing fixtures ?  Millwork ?  Patient orientation ?  Patient lift ?  Interior finishes ?  Headwall design - wall protection, gases, bumper rails, fixed equipment, monitor, light fixtures and ? switch location, data/power 67  Rooms Proponent 1 Proponent 2 Proponent 3 ? Bed controls ?  Glove dispensers ?  Privacy curtain Mediation rooms ? Medications room is accessible from Team Care station; ?  Controlled access cabinets, fridge and sink are along two walls in an L-shape; ?  Large windows do not interfere with equipment and room layout; ?  Minimum length = 1600mm ?  Minimum width = 1150mm ?  Electrical switches and outlets are standardized and placement is the same in room; and ?  Ceiling height = 2800 mm ?  Handwashing sink is located adjacent to door. ? Room access ? Layout of medical equipment  ? Impact of structure (windows, columns) on room flow ? Minimum length ? Minimum width ? Electrical (lighting and outlet location)  ? Ceiling heights ? Plumbing fixtures ? Room access ?  Layout of medical equipment ?  Impact of structure (windows, columns) on room flow ?  Minimum length ?  Minimum width ?  Electrical (lighting and outlet quantity and location, light switch quantity and location) ?  Ceiling heights ?  Plumbing fixtures ?  Millwork ?  Interior finishes ?  Glove dispensers Table 2.8 Standardization requirements68  2.3.1.2.4 Ability to safely monitor patients in the following areas (RFP 3.2.1.4 d) i)  Pre-Op/stage II recovery. Indicate team station location and sight lines from unit clerk location to all viewable decentralized care stations (a total of 3 locations for the entire department) As cited by proponent 1, the Pre-Op/level 2 recovery area is divided into two separate zones (each zone is a mirror image of the other) with centralized support in each zone for close proximity to medication rooms, soiled, clean and equipment storage, allowing care staff to view and support each other in the station itself as well between decentralized care stations. As shown in Figure B23, the two team care stations for the Pre-Op/level II recovery provide oversight of 18 patient bays from a total of  23, from the north pod, 11 care stations are visible, and from the south pod, 7 stations are visible.   As it shown in Figure B24, proponent 2 offers two primary and one secondary team care stations, each one has direct sight line to six care stations, resulting in a total of 18 decentralized care stations under direct sight.  From Figure B12 to B14 it is possible to identify that proponent 3 offers three team stations from where it is possible to oversight 22 care stations.   Even though all proponent layouts presented are different, it is possible to conclude that all three proponents suggest a layout that allows oversight of a greater number of care stations than offered by the indicative design. For this item the indicative design layout offers 2 team care 69  stations from where is possible to have 9 decentralized care stations under direct sight. For this item, the evaluation report shows that proponent 3 obtained the highest score.  Available points Indicative design Proponent 1 Proponent 2 Proponent 3 Number of  team care stations 2.5 2 2 3 3 Number of care station under direct sight 9 18 18 22 Table 2.9 Sight lines requirements from unit clerk location to all viewable decentralized care stations  ii)  PARR. Indicate team station location and sight lines from unit clerk location to all viewable head of patient beds (a total of 2 locations within one team care station). From Figure B25, it is possible to see that proponent 1 locates the single care station in PARR in such a way as to provide staff with visual sight lines to all 20 head locations as well as to the two entrances to the ante rooms for the airborne isolation rooms. However, the two isolation rooms are located behind the team care station, and thus a direct site line is not provided (it is necessary to turn around). The second proponent as shown in Figure B26 proposes a configuration from a seated position at two locations in the team care station. Unit clerks will be able to see to the head of all 20 patient beds as well as to the entries of the two air borne isolation ante rooms. Proponent 3 shows a layout that allows for a single team care station oversight of 20 patient beds and 2 ante rooms for the airborne isolation rooms.  70  The indicative design offers 18 private rooms and 2 isolation rooms. In terms of comparison with the indicative design (Figure A3 and A4), proponent 2 and 3 have the same number of rooms under direct sight. Proponent?s 1 layout has no direct sight to any isolation room.   For this criterion, according to the evaluation report proponents 2 and 3 obtained the maximum score available. Direct view to Available points Indicative design Proponent 1 Proponent 2 Proponent 3 Number of private rooms 6 18 20 20 20 Number of isolation rooms 2 2 2 2 Total number of rooms 20 22 22 22 Table 2.10 Sight lines requirements from unit clerk location to all viewable head of patient beds  2.3.2 Optimize clinical utilization (RFP 3.2.1.5) According to the RFP, the operational efficiency and effectiveness of caregivers in a hospital are greatly influenced by the facility?s physical design. A hospital is a very labour-intensive institution requiring considerable movement of materials, staff, patients and visitors. The planning and design process must result in a physical plan and the organization of components that will minimize operating costs and maximize the quality of service.    71  Proponents were told in the RFP that all design features that positively impact OR efficiency and turn over time were highly valued. For example: ? Utilize existing process flow maps (including but not limited to flow of the patients, families, stretcher/beds, medication, equipment/instrumentation, supplies/materials, communication, patient belongings, patient chart/information) and lean principals when designing spaces that will impact work flow. ? Organize the surgical suite to positively impact operating room turn over between cases. ? Organize the surgical suite such that equipment is readily available in a protected environment. ? Organize surgical supplies within the sterile core such that they are readily available. ? Locate key support spaces to ensure efficiency of movement of supplies and materials throughout the new facility and the rest of the campus to reduce the use of elevators and to optimize distribution, example of rooms such as medication rooms, housekeeping, soiled utility and the satellite lab. ? Allow direct visual supervision of patients in PARR from the care station. ? Allow direct visual supervision of the decentralized nurse stations in CSICU from the care station. ? Integrate ergonomic principles throughout the design as outlined in the RFP. ? Alleviate the need for staff to experience awkward postures, forceful exertions, contact stress, cognitive distraction and increased fatigue.   72  The RFP specifically requests each proponent to deliver the following information in terms of improving clinical utilization.(As explained in Chapter 1, only those criteria that have high score are relevant in terms of what is evaluated in this study (Table 1.2 Items to review in product view)).  2.3.2.1 Optimize clinical utilization - requirements  2.3.2.1.1 Location of storage spaces (RFP 3.2.1.5 b) Criterion: Distance from the OR and PARR to some storage facility.  Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the criteria indicated below. Elements Travel efficiency distance Travel route Available points Minimum score distance Maximum score distance OR to equipment .70 41.9 m 37.6 m OR to housekeeping .70 61.5 m 56.8 m OR to soiled utility .70 94.2 m 85.3 m PARR unit to clean utility .70 21.4 m 19.5 m Pre-Op to clean utility .70 36.2 m 32.0 m Table 2.11 Travel efficiency distance to storage space   73  2.3.2.1.2 Separation and efficiency of flows: public, patients and materials (RFP 3.2.1.5 c) Criterion: No Public Pathway shall cross a patient/logistics pathway.  Evaluation criteria: In order to evaluate and compare the proposals the evaluating team used the criteria indicated below. The minimum score is 0 points, which means 2 crossings and a maximum of 16 points which means no crossings.  Definitions included in the RFP: Pathway: A travel path a person would take using corridors and/or elevators connecting two locations. Public pathway: A public pathway is an interdepartmental corridor travel route connecting the public concourse to other public spaces. Public pathways can include elevators. Examples include the public concourse to CSICU waiting or the public concourse to surgery waiting area. Patient/logistics pathways: A patient/logistics pathway is an interdepartmental corridor travel route connecting departments. Patient/logistics pathways can include elevators. Examples include PARR to Pre-Op/level II recovery, Pre-Op/level II recovery, surgery or surgery to CSICU, or CSICU to level 2 Strathcona. Crossing: A crossing occurs when a public pathway physically crosses a patient/logistics pathway. Interdepartmental: A corridor that is not inside a department.  74  Exception 1: If the Pre-Op/level II recovery department is located on level 1, one patient/logistics pathway may cross the public pathway that serves as the public concourse. The intent of this exception is to allow logistics to the department on the east side of the public concourse. This exception only applies for this purpose. Exception 2: On level 2, one patient/logistics pathway may be crossed by the public pathway between the public elevators and the CSICU public areas. The intent of this exception is to allow the public elevators more freedom of location. This exception only applies for this purpose. The following pathways colors were indicated to the proponent in the RFP and are useful to understand the drawings in the appendices of this thesis.  The pathways are indicated as follows: ? Public pathway ? green; ? Patient pathway ? purple; ? Logistics pathway ? red; ? FM route ? blue;  2.3.2.1.3 Workflow within medical device reprocessing (MDR) (RFP 3.2.1.5 d) Criterion: The Authority?s objective regarding distance is to ensure the following: ? That soiled product entering the department is processed quickly; ? That sterile product leaving the department is easily transferred; and ? Workflow diagrams as described in the specifications and related to LEAN design have been fully integrated into the design.   75  Evaluation criteria: In order to evaluate and compare the proposals the evaluating team considered the following elements. Elements Travel efficiency distance Travel route Available points Minimum score distance Maximum score distance Soiled elevator measurement 1.25 12.6 m 11.34 m Soiled entry measurement 1.25 14.2 m 12.7 m Full case cart holding measurement 1.25 8.0 m 6.5 m Sterile entry measurement 1.25 21.5 m 17.2 m Table 2.12 Travel efficiency distance from medical device reprocessing (MDR)  Measurement item 1:  Soiled elevator to the following: (The measurements below will be averaged) ? Soiled elevator door (point A) to the center of the soiled receiving area (point B). ? Soiled elevator door (point A) to the center of each sink in the sorting and washing area (point B). ? Soiled elevator door (point A) to center of the soiled scopes room door (point B).  Measurement item 2: Soiled zone entrance to the following: (The measurements below will be averaged) ? Soiled entrance door (point A) to the center of the soiled receiving area (point B). ? Soiled entrance door (point A) to the center of each sink in the sorting and washing area (point B). ? Soiled entrance door (point A) to center of the soiled scopes room door (point B).   76  Measurement item 3: Full case cart holding area to the following: ? Clean elevator door (point A) to the center of the full case cart holding area (point B). Measurement item 4: Sterile stores area to the following: ? Center of sterile stores area (point A) to the center of the sterile zone door (point B).  Minimum distance: No measurement item shall be less than 4.5 meters. The intent of this requirement is to keep a clear area in front of the zone entrance or elevator.  Soiled entrance door: Means the door through which soiled material will enter the soiled zone from the interdepartmental corridor.  Sterile zone door: Means the door through which sterile material will leave the sterile zone to the interdepartmental corridor.  2.3.2.2 Optimize clinical utilization - assessment of innovation 2.3.2.2.1 Location of storage spaces (RFP 3.2.1.5 b) In terms of assessing innovation for this item, it is necessary to compare the indicative design with each proposal. According to the definition of innovation declared in Chapter 1, a significant improvement to the indicative design can be considered as innovation. In this specific item shorter distances between OR and PARR to storage spaces are considered positive factors. For this item it is also possible to compute a weighted score (linear interpolation) in order to determine a relative ranking of the proposals and being able to observe if distinctly differences in score appear. 77  As seen in Table 2.13, proponent 1 obtained the highest weighted score, followed by proponent 2. On the other hand, the evaluation report indicates a draw in terms of score between proponent 1 and 2.  The following table summarizes the travel efficiency distances for each type of room to storage space.   Travel efficiency distance    Travel route Available points Minimum score distance Maximum score distance Proponent 1 Proponent 2 Proponent 3 OR to equipment 0.7 41.9 m 37.6 m 16.8 m 28.87 m Info not available OR to housekeeping 0.7 61.59 m 56.8 m 57.7 m 77.7 m Info not available OR to soiled utility 0.7 94.24 m 85.3 m 58.3 m 66.25 m Info not available PARR to clean utility 0.7 21.43 m 19.5 m 9.8 m 17.74 m Info not available Pre-Op to clean utility 0.7 36.23 m 32.0 m 12.5 m 27.15 m Info not available Weighted score (Interpolation) 3.5   3.37  2.8  Info not available Table 2.13 Summary travel distances to storage spaces   ? OR to equipment: For this route, proponent 1 offers a design with eight storage equipment rooms located directly across from each of the operating rooms (Figure C1). Proponent 2, indicates in its proposals that the eight equipment storage rooms are located on the perimeter of the OR restricted corridor (Figure C2), spread primarily along the east side, with additional storage along the west and south sides. For this route, proponent 3 places five storage equipment rooms located around the OR?s (Figure C3). The indicative design only offers 1 area shared with case cart holding/sterile area. 78  ? OR to housekeeping and soiled utility: Proponent 1 indicates that the housekeeping room and soiled utility room for the OR?s are located on the surgical restricted sub sterile corridor close to each other (Figure C4). Proponent 2 offers one housekeeping closet located on the east side (Figure C5) and one soiled utility room located on the west periphery of the surgery restricted corridor (Figure C6). Proponent 3 locates housekeeping and soiled rooms off the OR area (Figure C7 to C10). For this item the indicative design considers 1 storage space between the OR and the housekeeping. All proponents meet this minimum requirement for this item. ? PARR and Pre-Op to clean utility: Proponent 1 locates one clean utility room in the center of the service core area (Figure C1) and two clean utility rooms on the Pre-Op area (Figure C1). Proponent 2 indicates that one clean supply room is located in the core area of PARR with access from either side (Figure C11) and two supply rooms in the Pre-Op area. Proponent 3 offers 2 clean supply rooms for the Pre-Op area and 1 clean supply room for PARR. All are central to the central care area (See Figure C7 to C10). In this case the indicative design indicates 1 storage room between the PARR and clean utility and 2 storage rooms between the Pre-Op and clean utility room.   79  The following table shows the number of storage locations for each travel route. Travel route Indicative design Proponent 1 Proponent 2 Proponent 3 OR to equipment 1 area shared with case cart holding/sterile area 8 8 5 OR to housekeeping 1 1 1 1 OR to soiled utility 1 1 1 1 PARR to clean utility 1 1 1 1 Pre-Op to clean utility 2 2 2 2 Table 2.14 Number of storage locations for each travel route  According to the configuration proposed by each proponent and comparing them with the indicative design, it is possible to say that proponents 1 and 2 present the most clever layout since they offer more storage rooms reducing the average distances to those spaces. For proponent 3 the distances are not given, but the less space for storage rooms can be seen as a disadvantage.   2.3.2.2.2 Separation and efficiency of flows: public, patients and materials (RFP 3.2.1.5 c) As it is shown Figure C12, proponent 1 offers three patient elevators, two public elevators and three logistics elevators. Also it is explained by proponent 1 that the public pathway (green) is crossed in the south side of the building with the patient and logistic pathway (purple and red respectively). Level 1 serves material and staff movement and provides staff access to the exterior courtyard. 80  Level 2 will primarily serve as a staff and patient corridor serving both pre-and post-operative patients. As cited in the proposal, this link will serve staff, and patients, public traffic will be limited only to families of the CSICU with a controlled section of the floor. On Figure C12 in level 2 is shown that patient?s visitors in CSICU may be coming from Strathcona via the link on level 2.  Proponent 2, as shown in Figures C13 to C16, indicates in its proposal that there are three public and three patient elevators and five logistics elevators. About the crossings, in level 1, the logistics pathway crosses the public pathway over the north/south corridor as its proceeds to the level one patient/service elevators. In level 2 the public pathway crosses the patient pathway where the public leave the public elevators to travel to the CSICU waiting area.  As it shown in Figures C17 to C22 proponent 3, in level one public and logistics share the corridor while they are heading to their respective elevators. On level 2, the public pathway crosses the patients? pathways when the public goes from the elevator to the CSIUC waiting area.  In this case, the indicative design as shown in Figures A1 to A6 has no crossings on level 1 and one crossing between the public and the patient/staff pathway. When comparing with the indicative design, it is not possible to conclude that any of the proposals present a significant improvement regarding the indicative design. According to the evaluation report, for this item all proponents obtained the same score.  81  Table 2.15 compares the indicative design and each proponent in terms of efficiency of flows of public, patient and logistics.  Available points Indicative design Proponent 1 Proponent 2 Proponent 3 Number of crossings (exceptions) 0.7 1 2 2 2 Number of patient elevators  3 3 3 3 Number of  public elevator  3 2 3 2 Number of  logistics elevator  5 but 3 shared with patients 3 5 but 3 shared with patients 4 but 3 shared with patients Table 2.15 Efficiency of flows of public, patient and logistics  2.3.2.2.3 Workflow within medical device reprocessing (MDR) (RFP 3.2.1.5 d) The following table shows the average distances from MDR to the indicated points.   Travel efficiency distance     Available points Minimum score distance Maximum score  distance Proponent 1 Proponent 2 Proponent 3 Measurement 1 soiled elevator 1.25 12.6 11.34 12.43 m 11.28 m 14.18 Measurement 2 soiled entry 1.25 14.2 12.7 9.69 m 11.25 m 15.32 Measurement 3 full case cart holding 1.25 8.0 6.5 5.81 m 6.42 m Info not available Measurement 4 sterile entry 1.25 21.5 17.2 10.18 m 14.13 m Info not available Weighted score (Interpolation) 6   3.92  5 Info not available Table 2.16 Average distances from MDR  82  A comparison between the distances indicated in the indicative design and the each proposal is shown in Table 2.16. According to the three proponents, the flow from decontamination to sterile store is unidirectional from west to east. Proponent 1, as shown in Figure C23 proposes to provide a distraction free environment by placing the long axis of the department facing south with continuous windows. The location of the MDR above the surgical suite allows for direct connection between the sterile core and the sterile zone in MDR via the convenience stairs adjacent to the clean elevator. The soiled elevator brings soiled case carts directly from the sub-sterile corridor on level 2 to the soiled receiving area in MDR. The space in front of the soiled elevator ensures there is sufficient space if multiple case carts arrive at once. With respect to distinct areas for decontamination and sterile zones, proponent 1 uses walls to separate the decontamination zone, the clean zone and the sterile zone. All three entrance areas have hand washing and gowning areas outside each zone. Instruments, consumables, drapes, etc are available in the process flow for selection by staff.  Proposal 2, as shown in Figures C24 and C25 provides unidirectional flows in to the MDR. According to proponent 2, the layout of each zone aligns workflow with the movement of material. Proponent 2 presents three exceptions to the one way flow: cart washer carts pass from the clean zone back into decontamination through the door to the east of the soiled elevator; instrument washer racks pass from clean zone back to decontamination through the door to the east of the soiled elevator; and, sterilizer carts pass from the clean zone and back into the sterile zone through the door to the east of the steam sterilizing area. In order to have a distraction free environment, proponent 2 locates the MDR on its own floor, and proposes the following strategies: include enclosed areas where functionally requires it: locate offices to provide 83  oversight to clean and sterile zones; provide direct, natural daylight in the decontamination and clean zones, and borrowed daylight in the sterile zone; the MDR staff lounge is located outside the department; ergonomic workstations, etc. Proponent 2 also offers a layout where each of the three MDR zones are separated by walls and access between zones is through one access controlled door only.   Analyzing differences between the proposals and the indicative design leads one to conclude that the main difference is the location of the MDR zone, which in the indicative design is located on the first level. All three proponents meet the specific requirements for this item. However, proponent 2 offers a layout with the shortest average distances between the MDR and the indicated points leading to the assertion that proponent 2 presents for this item the cleverest layout.   In order to have better insight about the performance of the layouts it is useful to compute a weighted score (linear interpolation) and determine a relative ranking. According to this computation it is possible to observe that proponent 2 obtained the highest score, followed by proponent 1. Even though proponent 1 has shorter distances than proponent 2 on three of four measurements, proponent 2 obtained the highest score because all the distances were less than the minimum distance established; therefore the highest score on each measurement. Proponent 1 received a discount because one of their distances was closest to the maximum distance allowed. Proponent 3 indicates (only two measures available) distances longer that the maximum allowed obtaining no points. 84  This ranking does not coincide with the ranking obtained by the evaluation report which indicates a draw with the highest scores between proponents 2 and 3, followed by proponent 1.  2.3.3 Wellness environment (RFP 3.2.1.6) This criterion refers to access to natural light. According to the RFP, spatial disorientation is reduced by windows as people orient themselves with landmarks and directional views. Also the RFP indicates that views of the exterior and natural light should be provided from/to all patient care areas and staff work areas wherever possible. The design will place patient and staff areas in locations that maximize daylight opportunities, including use of light wells and tubes. Exterior window sizes and configurations shall provide access to natural light while maintaining patient privacy and acoustical requirements. Where ever possible major circulation corridors should have natural light ?nodes? at their end points and ?borrowed? light from the exterior building to the internal hallways.   2.3.3.1 Wellness environment ? requirements 2.3.3.1.1 Access and quality of direct natural light for each room listed in table below (RFP 3.2.1.6.a.i, ii, iii) Criterion: How the design will achieve optimal natural light levels in the rooms described below. i) Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR; ii) Access and quality of borrowed light for CSICU, Pre-Op Stage II bays, PARR bays, care stations, MDR and staff lounges. 85  iii) Direct access to outdoor space (exterior courtyard or roof garden from staff lounges).  Evaluation criteria: Shown in Table 2.17 is how each item is evaluated.  Item Minimum Maximum Available points I Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR;  ? 10 PARR bays/rooms; ? 3 CSICU rooms; ? 15 Pre-Op/stage II recovery bays; ? 1 main staff lounge; ? 1 MDR decontamination ? 1 MDR clean zone. ? 20 PARR bays/rooms; ? 8 CSICU rooms; ? 22 Pre-Op/stage II recovery bays; ? 1 main staff lounge; ? 1 MDR staff lounge; ? 1 MDR decontamination; ? 1 MDR clean zone; ? 1 MDR sterile zone. 6 points II Access and quality of borrowed light for CSICU, Pre-Op stage II bays, PARR bays, care stations, MDR and staff lounges  ? 6 PARR bays/rooms; ? 3 CSICU rooms; ? 15 Pre-Op/stage II recovery bays; ? 1 MDR decontamination; ? 1 MDR clean zone; ? 1 MDR sterile zone; ? 1 CSICU care station; ? 1 PARR care station; and ? 1 Pre-Op care station 1. ? 20 PARR bays/rooms; ? 8 CSICU rooms; ? 44 Pre-Op/stage II recovery bays; ? 1 main staff lounge; ? 1 MDR staff lounge; ? 1 MDR decontamination; ? 1 MDR clean zone; ? 1 MDR sterile zone; ? 1 surgery control center; ? 1 CISCU Team Care Station; ? 1 PARR team care station; ? 1 Pre-Op team care station 1; and ? 1 Pre-Op Team care station 2. 3.5 points III Direct access to outdoor space (exterior courtyard or roof garden from staff lounges).  ? No direct access from staff lounges to exterior courtyards or roof garden ? Provide direct access to outside courtyards or roof garden for all staff lounges 2.5 points Table 2.17 Criteria to evaluate access and quality of direct natural light   86  2.3.3.2 Wellness environment - assessment of innovation This criterion is divided in three evaluation items:  2.3.3.2.1 Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR (RFP 3.2.1.6.a.i) As shown in Figure D1, the design of proponent 1 offers natural daylight to all eight patient rooms. Proponent 1 says that the waiting area for the visitors as well as the staff work area and the two family quiet rooms benefit from direct daylight in the visitor Area. The team care station also has natural light from a window in the station. Within the Pre-Op/stage II department 22 of the 44 bays have natural light. Situated on the north-east corner of level 2, the PARR department receives natural daylight from both the north and east providing daylight to 75% of the patient bays. The staff lounge is located on the first floor directly adjacent to the main courtyard receiving north light through the floor to ceiling windows complete with direct access to the main courtyard. The MDR is conceptually laid out as a rectangle with the long axis facing south with full windows.  Proponent 2 offers 10 patient bays located on the south face of the department that will benefit from, direct, natural light due to the southern exposure. In addition, the rest of the PARR area, including the team care station, will satisfy the daylight criterion due to the open nature of the department. Patient bays and the southern half of the care station will have views to Rose Avenue to provide a positive distraction. A light tube will provide borrowed light to the north side (10 rooms) of the team care station to further amplify the light levels in the department. 87  Proponent 2 locates the CSICU at the northwest corner of level 2 and all 8 patient rooms have been placed on the perimeter for access to direct natural light. As quoted by proponent 2 The Pre-Op/stage II recovery department has been located on the east side of level 1 and patient bays have been positioned on the three perimeter walls (north, east and south) to maximize the direct, natural, and borrowed light into the department. 24 patients from 42 bays will have access to direct, natural light throughout the day. The level one main staff lounge is located on the north perimeter wall with views and access to the central courtyard on two sides. The MDR department is located on the third floor and has been provided with both direct and borrowed natural light to create bright working spaces for staff.   Proponent 3 indicates that CSICU, Pre Op/stage II bays and PARR bays have been designed with a similar intent. It is explained by proponent 3 that 30 patient rooms and bays have been placed along the exterior wall for access to views and natural light. Central support areas associated with the team care station, including the medication, nourishment and equipment/supplies areas are designed as either open or glazed areas to allow light penetration and overall department views. Natural light in these areas will be controlled by integral blinds in the 8 CSICU and isolation patient rooms as well as the MDR. 14 PARR stretcher bays on the east side will also benefit from the exterior sun shading feature.   The MDR has been oriented north/south with a large expanse of east face exposure, allowing light into the decontamination, clean, and sterile zones.  88  The main staff lounge on level 1 and MDR lounge on level 2 will have direct sunlight and access to the outdoors.  Summarized in Table 2.18 is the number of rooms with direct access to natural light for each type of room. Table 2.18 Number of rooms with direct access to natural light  After analyzing the designs of each proponent, it is possible to conclude that all layouts try to maximize the access to natural light to all rooms, in terms of improving the indicative design; all proposals offer a design that meets and exceed the requirements. Proponent 3 was the one that offered the highest number of rooms with access to direct natural light.   According to the evaluation report, proponent 1 obtained the highest score between the proponents. However all of them were very close in terms of score. Type of room Available points Indicative design Proponent 1 Proponent 2 Proponent 3 PARR 6 10 16 10 14 CSICU 3 8 8 8 Pre-Op/stage II recovery bays 15 22 24 30 Main staff 1 1 1 1 MDR decontamination 1 1 1 1 MDR clean zone 1 1 1 1 MDR staff lounge 0 1 1 1 MDR sterile zone 0 1 0 1 89  2.3.3.2.2 Availability of borrowed and/or direct natural light as defined by the IHSC light measurement methodology document for each room as listed below (RFP 3.2.1.6.a. ii) Proponent 1, as shown in Figure D1, proposes a design for the CSICU that brings borrowed light into the decentralized care stations and the main access corridor for the CSICU patient care area. According to proponent 1, the circular design of each Pre-Op/stage II zone arrangement allows the patients and staff to benefit from the borrowed light coming through the windows as they move about the department. Similarly the remaining 25% of the PARR bays that do not have natural light benefit from the borrowed light.  Proponent 2 indicates that the PARR area has access to daylight due to the open nature of that area. A light tube will provide borrowed light to the central team care station in the CSICU area and the Pre-Op/stage II recovery team care station. Also indicated is that at the north end of the MDR department, the sterile zone will receive borrowed light through the adjacent glazed corridor and from a centrally-located skylight. Proponent 3 only indicates in its proposal that CSIUC, Pre-Op and PARR are provided with direct light. Borrowed light is not provided.   90  The following table summarizes the number of rooms with access to borrowed and/or direct light per type of room. Table 2.19 Number of rooms with access to borrowed and/or direct light  For this item as well as previous one, all proponents meet and exceed the minimum requirements. It is not possible to conclude that any of the proponents presents a particularly more clever layout in comparison to the others. Nevertheless, proponent 2 offers the highest number of rooms with access to borrowed and/or direct light per type of room. For this item, all proponents obtained the similar score and close to the maximum score available. Type of room Available points Indicative design Proponent 1 Proponent 2 Proponent 3 PARR 3.5 6 16 12 Not specified in proposal CSICU 3 8 8 Not specified in proposal Pre-Op/Stage II recovery bays 15 30 26 Not specified in proposal Main staff lounge 1 1 1 Not specified in proposal MDR decontamination 1 1 1 Not specified in proposal MDR clean zone 1 1 1 Not specified in proposal MDR staff lounge 1 1 1 Not specified in proposal MDR sterile zone 1 1 1 Not specified in proposal CSICU team care Station 1 1 1 Not specified in proposal Surgery control center 0 0 0 Not specified in proposal PARR team care station 0 1 1 Not specified in proposal Pre-Op team care station 1 0 1 1 Not specified in proposal Pre-Op team care station 2. 0 1 0 Not specified in proposal 91  2.3.3.2.3 Access to outdoor space (exterior courtyard or roof garden) from staff lounges (RFP 3.2.1.6.a.iii) Proponent 1, as shown in Figure D1, indicates on its proposal that the main staff lounge, located on the first floor directly adjacent to the exterior courtyard, receives north light through the floor to ceiling windows. The main staff lounge also accesses a portion of the main courtyard. The MDR staff lounge faces east with access to a roof garden balcony, receiving morning light. The staff work areas are placed on long axis of the department facing south with continuous windows providing natural light to the department. Also the front drop off from Pandosy Street is an extension of the Centennial building main entrance, providing ample views into the feature courtyard.  Proponent 2 indicates that the level 1 main staff lounge is located on the north perimeter wall with views and direct access to the courtyard on two sides. The lounge will therefore benefit from access to outdoor space, nature views, and daylight. Also indicated in the proposal is that the MDR staff meeting room/lounge is located at the northwest corner of level 3, overlooking the courtyard below. In addition to receiving direct natural light on both the north and west sides, the lounge opens onto an outdoor roof garden.   Proponent 3 indicates that the main staff lounge at level 1 will have ample frontage and access to the feature courtyard which includes a private staff zone with seating and landscaped areas. The MDR staff lounge will have exterior windows and direct access to an outdoor patio on level 2, with views to the east, north, and south.  92  With respect to the indicative design as shown in Figures A1 to A6, it does not offer direct access to outdoor space from the main staff located on level 3 and also does not offer access to outdoor space from MDR staff meeting room on level 1.   All proponents meet the requirements indicated in the RFP. In terms of layout it is possible to say that even though all 3 designs are different; all present a workable solution for access to outdoor space. Therefore, in this case using the definition of innovation previously stated in this thesis it is not possible to judge which proponent proposes a more superior design. According to the evaluation report all the proponents obtained the maximum score for this item.  2.3.4 Enhance site development features (RFP 3.2.1.7) This criterion category deals with the overall building exterior design and the perception of patients and visitors to the IHSC, including the building form and character, exterior materials and color, roofs, building entrances, exit and convenience stairs, corridors, etc. It also captures the flexibility of the design in terms of adaptation to the current and future environment and demand.   93  2.3.4.1 Enhance site development features ? requirements 2.3.4.1.1 Site parking and vehicular flows (RFP 3.2.1.7 b) Criterion: Site parking and vehicular flows will enable efficient and friendly access and egress to the site. The following points are evaluated according to AEDET4 methodology. The minimum score for this item is 21 out of 30 and the maximum is 30 out of 30 points, both using AEDET scoring methodology. The following AEDET statements (section in brackets) were evaluated: ? The building is clearly understandable (C.05). ? There is good access from available public transport including any on-site roads (I.01). ? There is adequate parking for visitors and staff cars with appropriate provision for disabled people (I.02). ? The approach and access for ambulances is appropriately provided (I.03). ? Goods and waste disposal vehicle circulation is good and segregated from public and staff access where appropriate (I.04).  Evaluation criteria: The evaluation criterion is based on the AEDET scoring methodology. For this specific review the weighting of all sections is assumed to be ?normal (1)?. No sections will be weighted as ?high (2)? and none of the sections will be weighted ?double?. If the section is not used the weighting will be ?Zero (0)?.  2.3.4.2 Enhance site development features - assessment of innovation. After analyzing the design proponent 1 regarding this item, it is possible to say that the building allows an efficient and friendly access. Traffic flows on site are managed by providing access                                                  4 ?Achieving Excellence Design Evaluation Toolkit? or AEDET is a scoring methodology developed by the United Kingdom National Health Service. 94  points, one-way roadways around buildings and accessible short-term parking for drop-off and pickup at entrances. The design includes emergency vehicle access, for both ambulances and fire trucks; cyclists; and service vehicles.   Regarding the access for public transportation, the design considers access for people traveling by bus and taxi. Public traveling by bus is dropped off at the relocated south bus stop, or if traveling north-bound at the existing bus stop directly across the street. Taxis have a dedicated parking stall located at the main KGH campus entrance into Centennial building.   Regarding parking for visitors and staff cars, the design includes 12 parking stalls for visitors to the east of the IHSC building. Staff park on the newly constructed parking facility to the south of the IHSC building. Disabled parking is provided in accordance with city by-laws and IHA specification and is located among the 12 angled parking spots for visitors. The approach for ambulance is considered in the design. There are two required ambulance parking stalls for drop-off and patient transfer under the covered portion of the southwest of the IHSC entrance as shown in Figure E1 (Appendix E). Service vehicles for deliveries, facilities management, and waste removal are segregated from public and staff access points at entrances. These service vehicle routes enter off Pandosy Street and head west on Rose Avenue to the loading dock located to the south of Strathcona building.  Proponent 2, also offers a fairly understandable building, with 12 vehicle parking stalls on the east side of the IHSC building, 5 lay-by stalls and one taxi stall at the centennial entrance, 6 lay-by stalls at the Rose Avenue entrance and 2 ambulance parking stalls at the Rose avenue 95  entrance (Figure E2). Regarding public transit, proponent 2 proposes relocating existing bus lay-by presently located directly east of the IHSC building southward to the front of the clinical academic campus building. The required curb cut for the bus lay-by has been extended to connect to the Rose Avenue curb, allowing for a lane for traffic leaving the site heading southward to properly merging with the Pandosy Street traffic. About parking for visitors, staff and disabled people, the proponent includes 12 parking spots located adjacent to the internal roadway along Pandosy Street, on the east side of the IHSC Building. Also 5 stalls at the Centennial entrance and 1 taxi stop are provided.   Concerning the approach and access for ambulances, the design of proponent 2 indicates that there are two non-emergency ambulance parking spaces adjacent to the entrance and under the building canopy. These two stalls are segregated from the other public lay-by stalls and are designed to allow the vehicles to back into the space. Ambulances will access the back-in ambulance parking stalls directly from Rose Avenue and will exit in either direction on Rose Avenue. The location of these stalls allows ambulance staff to unload patients without standing in or crossing any driveway. The access for goods and waste disposable vehicle will not affect the existing vehicular routes to the loading dock for deliveries or for waste collection. These vehicles will not be required to travel through the site on the internal road to access the loading area on Rose Avenue as they will be able to travel west on Rose Avenue directly from the intersection of Rose Avenue and Pandosy Street. Proponent 3 proposed an understandable design with public, staff and ambulance parking as shown in Figures E4 and E5. Two public site entrances are planned, one in the middle of the block along Pandosy Street at the Centennial building vehicle loop and another west of the 96  Pandosy Street/Rose Avenue intersection. Both entrances will be accessible to ambulances and private vehicles. The design includes parking for taxi and considers the relocation of the bus stop at the Rose and Pandosy Streets intersection.   Visitors and staff arriving in cars will proceed directly to the parkades along the southern side of Rose Avenue and then walk to the hospital. A limited number of parking spaces will be provided near the entrances. At the Pandosy Street entrance five drop off spaces plus a taxi lay-by are provided. Twelve more short-term angled stalls are proposed along the IHSC Project site lane connecting both entrances, two of which are disabled parking stalls. At the Rose Avenue entrance, a dedicated drop off zone is provided for two ambulances and six lay-by stalls are provided for people picking up patients from the Post-Op waiting lounge.  As it shown in Table 2.20, all the proponents meet the minimum requirements specified in the RFP.   97  Design and construction requirements Available points Proponent 1 Proponent 2 Proponent 3 Lay-by stalls for patient drop-off and pick-up only located adjacent to the Centennial building entrance and large enough to accommodate a minimum of 5 cars; 5 ? 5 lay-by stalls at the centennial main entrance. ? 6 lay-by stalls at the Rose avenue entrance ? 5 lay-by stalls at the centennial main entrance. ? 6 lay-by stalls at the Rose avenue entrance ? 5 lay-by stalls at the centennial main entrance.  Two non-emergency ambulance parking stalls for drop off and pick up for patients transferring to and from other facilities near the Rose Avenue IHSC entrance ? 2 two non-emergency parking stalls ? 2 two non-emergency parking stalls ? 2 two non-emergency parking stalls A minimum of 12 angled parking stalls on the East face of IHSC ? 12 angled parking ? 12 angled parking and 2 potential additional lay-by parking stalls ? 12 angled parking Provide a taxi zone for a minimum of one taxi cab at the Centennial Avenue entrance of the building. ? 1 taxi zone. ? 1 taxi zone. ? 1 taxi zone. Table 2.20 Designated parking  According to the evaluation report, for this item, only proponent 1 obtained a positive score. Proponents 2 and 3 did not obtain a score. 98  2.4 Conclusions Presented in Table 2.21 is a summary of the results obtained from the analysis of the product aspect of the proposals and indicative design. The outcome obtained from the analysis of the product aspect of the proposals and indicative design is an interpretation and judgment of the author of the information presented by PBC. One can conclude that all three designs seemingly outperform the indicative design for almost all criteria, or at worse achieve the same performance level.   The following comments place the work performed in perspective: 1) The approach of this thesis was an assessment of innovation of the IHSC project, specifically on the product aspect of the proposals and indicative design. For a complete view of the assessment refer to Melej 2013. 2) The research was based on the information available at the time of the study, which included the request for proposal, indicative design, score sheet and the technical proposals submitted by each proponent.  3) A significant challenge is to define a suitable and appropriate definition of innovation for construction projects. In order to assimilate information it is important to differentiate between what kinds of information is important and necessary to know and what would be optimal to have but hard or impossible to obtain.  4) The definition of innovation has to be broad enough that allows its application and find if there is some level of innovation in the proposals. The indicative design is employed as a base to compare the proposals in terms of the score sheet defined in the RFP. It is 99  observed that the proposal that scores best does not necessarily exhibit the highest level of innovation. 5) Presented in Table 2.21 is a summary of the findings obtain from the analysis along Chapter 2.  100    Metrics Units Indicative design Proponent 1 Proponent  2 Proponent 3  Product view      2.3.1 Enhance patient safety      2.3.1.2.1 Travel distances for surgical staff to patients       Distance Pre Op to OR m 167.1 134.71 105.52 Not available  Distance PARR to Pre-Op m 110.68 87.07 101.45 Not available  Distance OR to staff lounge m 103.49 69.08 72.87 Not available  Number of staircases connecting levels 1 and 2  n 4 1 3 3  Floor location OR  level 2 2 2 2  Floor location PARR level 2 2 2 2  Floor location CSICU level 2 2 2 2  Floor location staff lounge level 3 1 1 1  Floor Location Pre Op level 3 1,2 1 1 2.3.1.2.2 Travel distances for patient transport from cardiac ORs m      OR to PARR m 95.26 92.93 92.11 Not available  Cardiac OR to CSIUC m 52.84 39.91 46.72 Not available 101    Metrics Units Indicative design Proponent 1 Proponent  2 Proponent 3  Pre-Op to OR m 167.1 103.83 164.2 Not available  Number of patient elevators n 2 2 3 3 2.3.1.2.3 Standardization of rooms, bays and support areas List of standardized elements See Table 2.8 2.3.1.2.4 i) Ability to safely monitor patients in Pre-Op/stage II recovery  No of direct sight line      Number of team care stations n 2 2 3 3  Number of care station under direct sight n 9 18 18 22 2.3.1.2.4 ii) Ability to safely monitor patients in PARR No of direct sight line      Number of private rooms n 18 20 20 20  Number of Isolation rooms n 2 0 2 2  Total number of rooms n 20 22 22 22 2.3.2 Optimize clinical utilization      2.3.2.2.1 Travel distances from OR, PARR and Pre Op to storage rooms m      OR to equipment m 41.9 16.8 28.87 Info not available  OR to housekeeping m 61.59 57.7 77.7 Info not available  OR to soiled utility m 94.24 58.3 66.25 Info not available  PARR to clean utility m 21.43 9.8 17.74 Info not available  Pre-Op to clean utility m 36.23 12.5 27.15 Info not available 102    Metrics Units Indicative design Proponent 1 Proponent  2 Proponent 3 2.3.2.2.2 Number of storage rooms for each travel route       OR to equipment n 1 area shared with case cart holding/sterile area 8 8 5  OR to housekeeping n 1 1 1 1  OR to soiled utility n 1 1 1 1  PARR to clean utility n 1 1 1 1  Pre-Op to clean utility n 2 2 2 2  Number of crossings (exceptions) n 1 2 2 2  Number of patient elevators n 3 3 3 3  Number of public elevator n 3 2 3 2  Number of logistics elevator n 5 but 3 shared with patients 3 5 but 3 shared with patients 4 but 3 shared with patients 2.3.2.2.3 Average distances from MDR       Measurement 1 soiled elevator m 11.34 12.43 11.28 14.18  Measurement 2 soiled entry m 12.7 9.69 11.25 15.32  Measurement 3full case cart holding m 6.5 5.81 6.42 N/A  Measurement 4 sterile entry m 17.2 10.18 14.13 N/A 103    Metrics Units Indicative design Proponent 1 Proponent  2 Proponent 3 2.3.3 Wellness environment      2.3.3.2.1 Number of rooms with direct access to natural light       PARR n 10 16 10 14 CSIUC n 3 8 8 8 Pre-Op/stage II recovery bays n 15 22 24 30 Main staff n 1 1 1 1 MDR decontamination n 1 1 1 1 MDR clean zone n 1 1 1 1 MDR staff lounge n 0 1 1 1 MDR sterile zone n 0 1 0 1 2.3.3.2.2 Number of rooms with access to borrowed and/or direct light       PARR n 6 16 12 Not specified  CSIUC n 3 8 8 Not specified  Pre-Op/stage II recovery bays n 15 30 26 Not specified  Main staff lounge n 1 1 1 Not specified  MDR decontamination n 1 1 1 Not specified 104    Metrics Units Indicative design Proponent 1 Proponent  2 Proponent 3  MDR clean zone n 1 1 1 Not specified  MDR staff lounge n 1 1 1 Not specified  MDR sterile zone n 1 1 1 Not specified  CSICU team care station n 1 1 1 Not specified  Surgery control center n 0 0 0 Not specified  PARR team care station n 0 1 1 Not specified  Pre-Op team care station 1 n 0 1 1 Not specified  Pre-Op team care station 2 n 0 1 0 Not specified 2.3.4 Enhance site development features    Number of parking stalls  n See Table 2.20 Table 2.21 Product summary metrics   105  Chapter  3: Conclusions  3.1 Chapter overview The focus of this study, as stated in Chapter 1 is: (i) How to identify, measure and evaluate the innovation included in a proposal though a selection of  appropriate metrics ; (ii) Identify any substantial differences in the value of the metrics selected as per point (i), between the indicative design and the proponents for the Interior Health Surgical Centre  project; (iii) Judge if innovation contributed to the differences amongst proposals and the indicative design. The chapter is structured as follows. First, the objectives set for the thesis work are stated, followed by a summary of the methodology employed and challenges encountered. Then, conclusions are presented in summary form, followed by an elaboration of all metrics values considered. The chapter ends with observations on possible future work.  3.2 Objectives As presented in the first chapter of this work, specific thesis objectives are:  1. Provide insights about the studies and research available with respect to the topic of innovation in the construction industry and its relationship to choice of procurement mode; 106  2. Compile a set of metrics to simplify the  project characterization process, as well as a methodology to help the assessing of innovation in project proposals; 3. Identify specific innovations included in the proponent proposals regarding the product view of a project; and, 4. Seek to determine if innovation was the source of a significant difference in score amongst proposals for an individual criterion and overall project ranking for the project studied.  3.3 Research Methodology The methodology selected for this study is described as follows: ? Presented in Chapter 1 is the literature review performed for this study. The main subjects examined were: innovation in relation to construction projects, P3 in health care projects and experiences in different countries like Canada, Australia and the UK; ? The research was based on the information made available for this study, which included the request for proposal, indicative design, score sheet related to health care delivery, and the technical proposals submitted by each proponent. Not available was capital and life cycle cost information related to the indicative design as well as the proponent proposals; ? A particular driver for innovation for the IHSC project was the client?s value system, which is set out in the expression for adjusted net present cost (NPCadjusted) as articulated in the RFP, namely NPCadjusted = NPCbase - 263517*(min (score, 80) ? 30)) + NPCenergy in which NPCbase is the present worth of capital and life cycle costs for which the proponent is responsible, the 263517*(min (score, 80) ? 30) term is a surrogate for 107  healthcare delivery costs from the perspective of the client (e.g. patient safety, clinical optimization, etc.) and is treated as a ?revenue? that can be attributed to the effectiveness of proponent design, and NPCenergy is the present value of electricity and natural gas cost over the duration of the concession agreement. The values of NPCbase and NPCenergy for the indicative design as proponent proposals were not provided to the research team, although values were computed for the latter by the researchers. It is possible to see that in terms of the RFP, the maximum value of the revenue term that could be earned relative to the client?s affordability limit was equal to 50*0.263517/128.17 = 10.3% - clearly an incentive to pursue, but depending on proponent viewpoint, it might be more productive to seek reduction in NPCbase versus pursue the maximum score possible for the ?revenue? term. The point being made here is that the client value system, including the relative value of its different components guide or shape proponent behavior, with the proponent objective being to win, especially given the very substantial costs involved in bidding a P3 healthcare project.  ? Essential to the work was articulating a meaningful description of innovation. For this specific work,  a refined definition was selected based on broader definitions found in the literature review ((Russell et al. 2006)); ?The use of advanced technologies, methodologies, and clever ideas that result in a positive incremental change compared to the indicative design?. This is broader than many definitions set out in the literature available, some of which are quite restrictive and require that before something can be declared an innovation. ? Accompanying the foregoing definition of innovation used is determining how to identify its presence through measurement of one or more metrics. The decision adopted for this 108  study was to look for substantive differences in performance amongst designs, including the indicative design when sufficient information was available, and then pass judgment as to whether or not part or all of the difference arose from the presence of innovation. Thus, a relative measure of innovation is used. There could be a flaw in this approach, in that all designs as they pertain to a specific metric could be innovative, and hence, two situations could arise: there is little difference amongst criterion scores, hence the existence of innovation would not be flagged despite its presence in all three, or, there could be a substantive difference in scores, but still innovation present in the lower scoring proposals. Both of these situations were not encountered in this study, based on the information available.  3.4 Challenges In this research many challenges were encountered. Some challenges are listed below: ? Since the study was based on the review of the RFP and the comparison with the three proposals submitted for the IHSC project, a large amount of information needed to be processed and analyzed. The volume of material and the differences in the level of detail given by each proponent made harder the characterization and comparison between them. Further, the information available represents at best about 25-30% design completion, so detailed information on what was being proposed was at times quite sketchy. ? For the purpose of this study, the assessment of innovation was performed using the material and information provided by Partnerships PBC, which consisted of the RFP documents including the indicative design and supporting documents As noted 109  previously, capital and life cycle cost information was not made available, largely because of the sensitivity of this information. ? As noted previously, development of a working definition of innovation suitable for a project like the IHSC project, and for the level of information available is a challenge. As defined in the methodology section, the definition provided has worked reasonably well.  ?  The assessment of the presence of innovation can be subjective, since it depends on who is evaluating it - factors such as environment, culture, venue, project type, and experience can influence determining what is innovative. Simply stated, what may be innovative for some people or organizations can be trivial and common for others.  3.5  Summary of conclusions An overview of the conclusions that can be drawn from this work is as follows: 1. An extensive literature review was performed during the execution of this research in order to gain insight about innovation in the construction industry. Various definitions of innovation were identified, and a flexible somewhat liberal and broad one was adopted for the study. No information was found of studies that compared proposals of a specific project, and academic research for assessing innovation in the construction industry 2. Significant differences were found to exist between the proposals made and the indicative proposal. For most metrics, proponent proposals outscored the indicative design (Table 3.1). Upon reflection, this is not surprising given that the worst performance level of interest was set at the value associated with the indicative design (e.g. travel distances, with small distances being preferred to larger ones). Nevertheless, normally it would be anticipated that some aspects of the indicative design would be superior to proponent 110  designs. This topic needs further exploration, and more information is required as to the charge given to the indicative design team and the time allocated for development of the indicative design.   Dimension Description An area of potential innovation in IHSC? Service Delivery (service delivery points converted to NPV (treated as revenue) Enhance Patient safety Aims to reduce patient travel distances and maximize logistical space planning Yes - through an optimization of the internal layout (scored item). Proponent 1 and 2 are distinctly superior to the indicative design. with proponent 1 being slightly superior to proponent 2 Optimize clinical utilization The objective is minimize operating cost and maximize quality of services  Yes- through an efficient planning, design process and organization of components. In this case, proponent 1 and 2 are distinctly superior to the indicative design. Proponent 2 is slightly superior to proponent 1.  Wellness environment Deals with access and quality of natural light   Yes- By locating patient and staff areas in locations that maximize daylight. Window sizes and configurations also help to provide access. Significant differences especially in number of PARR, CSICU and Pre-op rooms were found between proponents and the indicative design. Enhance site development features Deals with the overall exterior building design and the perception of patients and visitors No- In terms of number of parking stall and vehicular flows, no significant differences were found amongst proposals Table 3.1 Potential innovation  3. It is reasonably clear that adopting a performance based specification as opposed to a presriptive specification allows proponents to explore different ideas as to how best to fulfill a client?s needs. And perhaps even more importantly, a performance based specification requires the client to articulate carefully and in writing their needs and the rationale behind them, along with specifying in a tangible and measurable way their value system. Traditional procurement could benefit from such an approach ? i.e. provide a 111  detailed written brief to the design team, so that a means exists to assess the responsiveness of a design. This would perhaps be superior to a value engineering process tacked on at the end.  3.5.1 Product perspective analysis  A summary of the product metric values (Table 3.2) is presented in the following section. The table includes metrics in terms of product perspective and in some cases normalization relative to the indicative design or the proposal with the best performance for a specific metric. Also shown in the table are the bounds of performance sought by the client. A design that exceeded an upper distance bound would receive a zero score for that particular metric. A design that was better than a lower distance bound would get full marks, but no more. The upper bounds on distance measures were derived from the indicative design, which means that the indicative design would earn zero points for that particular metric. For other metrics such as the counting of rooms or stairwells, in some cases more components would be better than less, but a non-zero score could be earned, even for the indicative design.   112  3.5.2 Product perspective 3.5.2.1 Enhance patient safety 3.5.2.1.1 Ease of vertical/horizontal access (travel route) for surgical staff to patients (assuming staff use of stairs).  Proponents 1 and 2 presented solutions that are consistently and substantively superior to the indicative design in terms of shorter travel distances. Differences between proponents were less. A reasonable conclusion is that proponents either had a better understanding of how best to allocate space, better technology in making spatial allocation decisions, or were cleverer in making decisions.  A weighted score (simple linear interpolation of the score) was computed in order to find significant differences in score (see Table 3.2). For this specific case, all proponents indicate shorter distances than the maximum score distances; thus all obtained the highest score available (15.5 points) while the indicative design earned zero points. The ranking obtained by interpolation coincides with the one indicated in the evaluation report which assigned the maximum score available to each proponent. The reason is that although they offer different layouts, all of them are compliant and exceed the indicative design and the scoring system does not give more points even if the minimum requirements are exceeded (actual distances are shorter than the best distance in the requirements).    113  3.5.2.1.2 Travel efficiency measurement; patient transport routes (via elevators) Again, proponents 1 and 2 presented solutions that are consistently superior to the indicative design, but a substantive difference does not exist for all distance metrics in this category. Overall, proponent 1 scored the best by a substantial margin. Their space planning was substantively superior to both proponent 2 and the indicative design (a weighted score of 10.45 vs. 7.75 for proponent 2 and 10.45 vs. 0 for the indicative design). Regrettably, distance metric information was not available for proponent 3. This ranking (obtained by interpolation) coincides with the ranking indicated in the evaluation report developed by the evaluation team.  3.5.2.1.3 Standardization of rooms, bays and support areas with regard to key areas of CSICU, PARR, Pre-Op and stage II recovery bays and medication rooms  All proponents meet the standardization requirements for the rooms indicated in the RFP. Except for the metric ?Number of care stations under direct site?, differences between proponent designs and the indicative design appears to be modest although on the positive side, while differences amongst proponent designs were minimal. Seemingly all proponents made improvements to the layout. Overall this metric does not appear to be a source of innovation.   3.5.2.1.4 Ability to safely monitor patients  Marginal improvements to the indicative design by proponents occurred for this metric.    114  3.5.2.1.5 Enhance patient safety ? summary In terms of innovation, it is feasible to assert that proponents 1 and 2 were clearly superior in their layout of spaces in a manner which reduced travel distances as compared to the indicative design, and proponent 1 was superior to proponent 2. One has to view these results in terms of other spatial layout tasks before a judgment of overall superiority of one proposal over another can be made.  3.5.2.2 Optimize clinical utilization  3.5.2.2.1 Location of storage space For this metric, in almost all cases the designs of proponents 1 and 2 were superior to the indicative design. Between proponents 1 and 2, proponent 1 was superior to proponent 2 for all distance measures treated. In terms of relative scoring, the difference is somewhat modest. Again, it appears that proponent teams are more proficient than the indicative design team, and proponent 1 team is the most proficient of the two proponent teams. While proponent 1 obtained the highest weighted score using interpolation, the evaluation report indicates a draw in terms of score between proponent 1 and 2.  3.5.2.2.2 Workflow within medical device reprocessing Analyzing differences between the proposals and the indicative design leads one to conclude that the main difference is the location of the MDR zone, which in the indicative design is located on the first level. All three proponents meet the specific requirements for this item. Except for one metric, it is observed that all proponent designs are superior to the indicative design. Interestingly, proponent 2 obtained the highest score (5) vs. 3.92 for proponent 1, a role reversal 115  in comparison to previous distance metrics described even though proponent 1 has shorter distances than proponent 2 on three of four measurements. Proponent 2 obtained the highest score because all the distances were less than the minimum distance established; therefore the highest score possible was achieved for each measurement. Proponent 1 received a discount because one of their distances was in excess of the maximum distance allowed. Proponent 2 was ranked by the evaluation team as being superior to proponent 1 for this metric.  3.5.2.3 Wellness environment 3.5.2.3.1 Access and quality of direct natural light for CSICU, Pre-Op/ stage II bays, PARR bays, staff lounge and MDR After analyzing the designs of each proponent, it is possible to conclude that all layouts try to maximize the access to natural light to all rooms, and provide improvements over the indicative design. All proponent proposals offer a design that exceeds the requirements. Proponent 3 was the one that offered the highest number of rooms with access to direct natural light. According to the evaluation report, proponent 1 obtained the highest score between the proponents. However all of them were very close in terms of score.  3.5.2.3.2 Availability of borrowed and/or direct natural light as defined by the IHSC light measurement methodology For this item as well as the previous one, all proponents exceeded the minimum requirements, although it is not possible to conclude that any one proponent presents a particularly cleverer layout in comparison to the others. Nevertheless proponent 2 offers the highest number of rooms 116  with access to borrowed and/or direct light per type of room. For this item, all proponents obtained the similar score and close to the maximum score available.  3.5.2.3.3 Access to outdoor space (exterior courtyard or roof garden) from staff lounges All proponents meet the requirements indicated in the RFP. In terms of layout it is possible to say that even though all 4 designs are different (proposals and indicative design); all present a workable solution for access to outdoor space. According to the evaluation report all the proponents obtained the maximum score for this item. However, it is not possible to conclude that any of the solutions offered were characterized by significant innovation.  3.5.2.4 Enhance site development features ? 3.5.2.4.1  Site parking and vehicular flows  All proponents provided a different layout as a valid alternative to the indicative design with respect to site parking and vehicular flows. Interestingly, only proponent 1 was awarded a positive score by the RFP evaluation team. No assertion is made here as to the presence of innovation.    117  3.6 Analysis of the results After characterizing each proposal and comparing them to the indicative design, it is reasonable to conclude that all proposals complied with the request for proposals regarding space, distribution and serviceability and provided improved performance regarding to the metrics of interest over and above the indicative design.  Cleverness in terms of space layout to create adjacencies that allow for the minimization of travel distance and exposure to natural light, and very efficient design of the HVAC system. These areas of innovation were driven by the desire to win by the proponents involved, but perhaps more important by the clarity with which the client?s value system was articulated, both in terms of function of building program requirements and how proposals will be evaluated.   At the end of the day, the winning proposal was one that did a ?workmanlike? job with respect to the provision of healthcare services within the facility once in operation and with respect to sustainability, especially in regard to energy consumption. By ?workmanlike? is meant a professional job that exceeded expectations as set out in the indicative design, but not one that reached a pinnacle of achievement.   The metrics assembled for measuring performance and identifying potential areas of innovation were extensive in scope, and incorporated metrics of interest in the healthcare sector and represent a work in progress.   118  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation Product view         2.3.1 Enhance patient safety         Travel distances for surgical staff to patients         Distance Pre Op to OR m 167.1 145.5 167.1 134.71 105.52 Not available  Distance Pre Op to Or relative to the indicative design    1 0.8 0.63 Not available Yes Distance PARR to Pre-Op m 110.68 120.8 110.68 87.07 101.45 Not available  Distance PARR to Pre-Op Or relative to the indicative design    1 0.79 0.91 Not available Yes Distance OR to staff lounge  m 103.5 93.2 103.5 69.08 72.87 Not available  Distance OR to staff lounge relative to the indicative design    1 0.66 0.70 Not available yes Number of stairs connecting level 1 and 2 n   4 1 3 3  Location OR Level   2 2 2 2  Location PARR Level   2 2 2 2  Location CSICU Level   2 2 2 2  Location staff lounge Level   3 1 1 1  Location Pre Op Level   3 1,2 1 1  Weighted scored (out of 15.5)    0 15.5 15.5 Not available  Relative score amongst proposals re distances for surgical staff to patients     1 1 Not available  Travel distances for patient transport from cardiac ORs         OR to PARR m 95.2 80.8 95.2 92.93 92.11 Not  119  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation available OR to PARR relative to the indicative design    1 0.97 0.96 Not available  Cardiac OR to CSIUC m 52.8 48.3 52.8 39.91 46.72 Not available  Cardiac OR to CSIUC relative to the indicative design    1 0.75 0.88 Not available Yes Pre-Op to OR m 167.1 145.3 167.1 103.83 164.2 Not available  Pre-Op to OR relative to indicative design    1 0.62 0.98  Yes Number of patient elevators n   2 2 3 3  Weighted scored (out of 15.5)    0 10.45 7.75 Not available  Relative score amongst proposals re distances for from cardiac ORs     1 0.74 Not available  Standardization of rooms, bays and support areas Standardized elements   See Table 2.8 Product view  Ability to safely monitor patients in Pre-Op/Stage II recovery No of direct sight line        Number of  team care stations n   2 2 3 3  Number of care station under direct sight n   9 18 18 22  Number of care station under direct sight relative to the indicative design    1 2 2 2.4 yes Ability to safely monitor patients in PARR No of direct sight line        Number of private rooms n   18 20 20 20  Number of isolation rooms n   2 0 2 2  Total number of rooms Level   20 22 22 22  2.3.2 Optimize clinical utilization         120  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation Travel distances from OR, PARR and Pre Op to Storage rooms m        OR to equipment m 41.9 37.6 41.9 16.8 28.87 Not available  OR to equipment relative to the indicative design    1 0.4 0.68 Not available Yes OR to housekeeping m 61.59 56.8 61.59 57.7 77.7 Not available  OR to housekeeping relative to the indicative design    1 0.93 1.26 Not available Yes OR to soiled utility m 94.24 85.3 94.24 58.3 66.25 Not available  OR to soiled utility relative to the indicative design    1 0.61 0.7 Not available Yes PARR to clean utility m 21.43 19.5 21.43 9.8 17.74 Not available  PARR to clean utility relative to the indicative design    1 0.45 0.82 Not available Yes Pre-Op to clean utility m 36.23 32 36.23 12.5 27.15 Not available  Pre-Op to clean utility relative to the indicative design    1 0.34 0.74 Not available Yes Weighted scored (out of 3.5)    0 3.37 2.8 Not available  Relative score amongst proposals Travel distances from OR, PARR and Pre Op to Storage rooms     1 0.83 Not available  Number of storage rooms for each travel route n        OR to equipment n   1  8 8 5  121  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation OR to housekeeping n   1 1 1 1  OR to soiled utility n   1 1 1 1  PARR to clean utility n   1 1 1 1  Pre-Op to clean utility n   2 2 2 2  Number of crossings (exceptions) n   1 2 2 2  Number of patient elevators n   3 3 3 3  Number of  public elevator n   3 2 3 2  Number of  logistics Elevator n   5 but 3 shared with patients 3 5 but 3 shared with patients 4 but 3 shared with patients  Average distances from MDR m        Measurement 1 soiled elevator m 12.6 11.34 12.6 12,43 11,28 14,18   Measurement 1 soiled elevator relative to the indicative design    1  0.98 0.89 1.12 Yes Measurement 2 soiled entry m 14.2 12.7 14.2 9.69 11.25 15.32  Measurement 2 soiled entry housekeeping relative to the indicative design    1 0.68 0.79 1.07 Yes Measurement 3 full case cart holding m 8 6.5 8 5.81 6.42 Not available  Measurement 3 full case cart holding relative to the indicative design    1 0.72 0.80 Not available Yes Measurement 4 sterile entry m 21.5 17.2 21.5 10.18 14.13 Not available  Measurement 4 sterile entry relative to the indicative design    1 0.47 0.65 Not available Yes Weighted scored of average distances from MDR (out of 6)    0 3.92 5 Not available  122  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation Relative score amongst proposal re optimize clinical utilizations     0.78 1 Not available  2.3.3 Wellness environment         Number of rooms with direct access to natural light n        PARR n   10 16 10 14  PARR relative to the indicative design    1 1.6 1 1.4 Yes CSIUC n   3 8 8 8  CSIUC relative to the indicative design    1 2.7 2.7 2.7 Yes Pre-Op/Stage II recovery bays n   15 22 24 30  Pre-Op/Stage II recovery bays  relative to the indicative design    1 1.5 1.6 2 Yes Main staff n   1 1 1 1  MDR decontamination n   1 1 1 1  MDR clean zone n   1 1 1 1  MDR staff lounge n   0 1 1 1  MDR sterile zone n   0 1 0 1  Number of rooms with access to borrowed and/or direct light n        PARR n   6 16 12 Not available  PARR relative to the indicative design    1 1.6 2 Not available  CSIUC n   3 8 8 Not available  CSIUC relative to the indicative design    1 2.7 2.7 Not available  Pre-Op/Stage II recovery bays n   15 30 26 Not available  123  Metrics Units Distance for min. score Distance for max. score Indicative Design Proponent 1 Proponent 2 Proponent  3 Area of potential innovation Pre-Op/Stage II recovery bays  relative to the indicative design    1 2 1.73 Not available Yes Main staff lounge n   1 1 1 Not available  MDR decontamination n   1 1 1 Not available  MDR clean zone n   1 1 1 Not available  MDR staff lounge n   1 1 1 Not available  MDR sterile zone n   1 1 1 Not available  CSICU team care station n   1 1 1 Not available  Surgery control center n   0 0 0 Not available  PARR team care station n   0 1 1 Not available  Pre-Op team care station 1 n   0 1 1 Not available  Pre-Op team care station 2, n   0 1 0 Not available  2.3.4 Enhance site development features         Number of parking stalls n   See Table 2.20 Product view Table 3.2 Product summary  124  3.7 Future Work Within the scope of this research, the recommendations for future work are: 1) The focus of this thesis was on characterizing proposals and indicative design for a specific project. A useful extension to the work would be to conduct an examination of other projects. With this it would be possible to validate the methodology adopted and also identify trends and items where innovation is commonly presented. 2) Future studies should explicitly treat both capital costs and life cycle costs. Even just having the capital and life cycle cost estimates for the indicative design could be of significant value in the assessment process. 3) An area that should be explored is preparation of the indicative design, and how competitive it should be as a point of departure for proponents.  4) Lastly, work should continue on compiling an exhaustive literature survey with emphasis on case studies of actual projects.    125  References Ball, R., Heafey, M., and King, D. 2000. Private Finance Initiative ? a good deal for the public purse or a drain on future generations?? 29: 95?108. Barlow, J., and K?berle-Gaiser, M. 2008. The private finance initiative, project form and design innovation. Research Policy 37: 1392?1402. Blayse, A.M., and Manley, K. 2004. Key influences on construction innovation. Construction innovation 4: 143?154. European Commission. 1995. Green Paper on Innovation. Available from http://europa.eu/documents/comm/green_papers/pdf/com95_688_en.pdf [accessed 20 April 2013]. Gambatese, J. a., and Hallowell, M. 2011. Enabling and measuring innovation in the construction industry. Construction Management and Economics 29: 553?567. Garvin, M.J. 2003. Role of Project Delivery Systems in Infrastructure Improvement. Construction Research Congress. Leiringer, R. 2006. Technological innovation in PPPs: incentives, opportunities and actions. Construction Management and Economics 24: 301?308. Liddle, B.T. 1997. Privatization Decision and Civil Engineering Projects. Journal of Management in Engineering 13: 73?78. Ling, F.Y.Y. 2003. Managing the implementation of construction innovations. Construction Management and Economics 21: 635?649. McKee, M., Edwards, N., and Atun, R. 2006. Public-private partnerships for hospitals. Bulletin of the World Health Organization 84: 890?896. Partnerships British Columbia. 2003. An Introduction to Public Private Partnerships. Available from http://www.partnershipsbc.ca/pdf/An Introduction to P3 -June03.pdf [accessed 13 March 2013]. Partnerships British Columbia. 2005. Achieving Value for Money Abbotsford Regional Hospital and Cancer Centre Project. Available from http://www.partnershipsbc.ca/files_2/documents/020705_PBCAbbotsford.pdf [accessed 13 March 2013]. Partnerships British Columbia. 2008. Achieving Value for Money Royal Jubilee Hospital Patient Care Centre. Available from http://www.viha.ca/NR/rdonlyres/0D9EAE3D-C884-4053-126  83B9-456D5FE6E5D4/0/rjh_project_report_vfm_oct08_final.pdf [accessed 13 March 2013]. Partnerships British Columbia. 2009. Achieving Value for Money Surrey Outpatient Hospital. Available from http://www.partnershipsbc.ca/files-4/documents/sof_vfm_final_web_20090603.pdf [accessed 13 March 2013]. Partnerships British Columbia. 2012. Interior Heart and Surgical Centre Project Report. Available from http://www.partnershipsbc.ca/files-4/documents/PBCIHSC.pdf [accessed 13 March 2013]. Russell, A.D., Tawiah, P., and de Zoysa, S. 2006. Project innovation ? a function of procurement mode?? 1. Canadian Journal of Civil Engineering 33: 1519?1537. Schumpeter, J.. 1961. The theory of Economic development: An inquiery into profits, capital, credit, interest, and the business cycle. Oxford University Press, New York. Siemiatycki, M., and Farooqi, N. 2012. Value for money and Risk in Public ? Private Partnerships. Journal of American Planning Association 78: 286?299. Slaughter, E.S. 2000. Implementation of construction innovations, Building Reseacrh & Information. Building Research & Information 28: 2?17. Taylor, R. 2002. Public Hospitals: Options for Reform through Public-Private Partnerships. Available from www.worldbank.org/html/pdf/notes/ [accessed 25 March 2013]. The Canadian council for public-private partnerships. 2003. The Canadian Case for Hospital PPP Projects. The Canadian council for public-private partnerships. 2013. The Canadian Council for Public-Private Partnerships. Available from http://projects.pppcouncil.ca/ccppp/src/public/search-project?pageid=3d067bedfe2f4677470dd6ccf64d05ed [accessed 26 August 2013]. Wall, A., and Connolly, C. 2009. The Private Finance Initiative. Public Management Review 11: 707?724.    127          Appendices Source: drawings provided by Partnerships BC  128         Appendix A: Indicative design    129   Figure A1 Indicative design site plan 130   Figure A2 Indicative design level 1 131   Figure A3 Indicative design level 2 132   Figure A4 Indicative design level 3 133   Figure A5 Indicative design level 4 134   Figure A6 Indicative design level 1 135         Appendix B: Enhance patient safety   136   Figure B1 Proponent 1 travel distance Pre Op to OR level 1 and 2 137   Figure B2 Proponent 1 travel distance PARR to Pre-Op level 1 and 2 138   Figure B3 Proponent 1 travel distance Pre-Op to OR lounge level 2 139   Figure B4 Proponent 2 travel distance Pre-Op to OR lounge level 1 140   Figure B5 Proponent 2 travel distance Pre-Op to OR lounge level 2 141   Figure B6 Proponent 2 travel distance PARR to Pre-Op lounge level 1 142   Figure B7 Proponent 2 travel distance PARR to Pre-Op lounge level 2 143   Figure B8 Proponent 2 travel distance OR to Staff lounge level 1 144   Figure B9 Proponent 2 travel distance OR to staff lounge level 2 145   Figure B10 Proponent 3 overall floor level 1 A 146   Figure B11 Proponent 3 overall floor level 1 B 147   Figure B12 Proponent 3 patient safety level 1 A 148   Figure B13 Proponent 3 patient safety level 1 B 149   Figure B14 Proponent 3 patient safety level 2 A 150   Figure B15 Proponent 3 patient safety level 2 B 151   Figure B16 Proponent 1 travel distance from Pre-Op to clean utility level 1 and cardiac OR to CSIUC level 2 152   Figure B17 Proponent 1 travel distance from Pre-Op to OR 153   Figure B18 Proponent 1 travel distance from OR to PARR 154   Figure B19 Proponent 2 travel distance from OR to PARR 155   Figure B20 Proponent 2 travel distance from OR to CSICU 156   Figure B21 Proponent 2 travel distance from Pre-Op to OR level 1 157   Figure B22 Proponent 2 travel distance from Pre-Op to OR level 2 158   Figure B23 Proponent 1 sightlines from unit clerk to decentralized care station 159   Figure B24 Proponent 2 sightlines from unit clerk to decentralized care station 160   Figure B25 Proponent 1 sightlines from unit clerk to head of patients beds 161   Figure B26 Proponent 2 sightlines from unit clerk to head of patients beds 162          Appendix C: Optimize clinical utilization   163   Figure C1 Proponent 1 distances from OR to equipment storage room and PARR to clean utility  164   Figure C2 Proponent 2 storage spaces in OR restricted corridor  165   Figure C3 Proponent 3 clinical optimization level 2 B  166   Figure C4 Proponent 1 clinical optimization level 2  167   Figure C5 Proponent 2 housekeeping room in surgical restricted corridor  168   Figure C6 Proponent 2 soiled utility room in surgical restricted corridor  169    Figure C7 Proponent 3 floor plan clinical utilization level 1 A 170    Figure C8 Proponent 3 floor plan clinical utilization level 1 B  171   Figure C9 Proponent 3 floor plan clinical utilization level 2 A 172    Figure C10 Proponent 3 floor plan clinical utilization level 2 B  173     Figure C11 Proponent 2 from ORs to soiled utility room  174     Figure C12 Proponent 1 optimized clinic utilization flow level 1 to 3 175    Figure C13 Proponent 2 circulation flows level 1  176   Figure C14 Proponent 2 circulation flows level 2  177    Figure C15 Proponent 2 circulation flows level 3 178   Figure C16 Proponent 2 circulation flows level 4  179    Figure C17 Proponent 3 floor plan clinical utilization level 1 A  180    Figure C18 Proponent 3 floor plan clinical utilization level 1 B  181   Figure C 19 Proponent 3 floor plan clinical utilization level 2 A  182   Figure C20 Proponent 3 floor plan clinical utilization level 2 B  183   Figure C21 Proponent 3 floor plan clinical utilization level 3 A  184   Figure C22 Proponent 3 floor plan clinical utilization level 3 B  185   Figure C23 Proponent 1 optimized clinical utilization MDR flows level 3  186   Figure C24 Proponent 2 optimized clinical utilization decontamination zone  187    Figure C25 Proponent 2 optimized clinical utilization MDR flows sterile zone  188          Appendix D: Wellness environment    189   Figure D1 Proponent 1 floor plan direct natural light level 1-2-3  190    Figure D2 Proponent 2 daylight and light tube in PARR  191   Figure D3 Proponent 2 CSICU daylight  192   Figure D4 Proponent 2 daylight in Pre-Op/stage II recovery room 193   Figure D5 Proponent 2 daylight in the level 1 staff lounge   194   Figure D6 Proponent 2 daylight in MDR  195          Appendix E: Enhance site development features   196   Figure E1 Proponent 1 parking and vehicular access  197   Figure E2 Proponent 2 parking spaces.  198   Figure E3 Proponent 2 emergency routes.  199   Figure E4 Proponent 3 circulation plan. 200    Figure E5 Proponent 3 parking plan 

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