The Conclude Consultancy

The Conclude Consultancy has just been appointed to carry out a strategic analysis in Northern Gothenburg for five regional surgery centres.  The planning of a new service in Uddevalla also forms a key part of the work. This appointment is endemic of a larger need for healthcare infrastructure owners, which is to establish much more realistic forecasts of patient demand than has hitherto been possible. With the advent of geo-located data, and powerful mapping systems, these enable Conclude to analyse the causal factors of demand and to investigate the impact of them on the location and sizing of new infrastructure. The influx data that is generated from this analysis becomes the critical data that Conclude utilises in their Occupancy Analytics (TM) methodology for the planning and analysis of specific facilities.

In emerging economies investors in health infrastructure need reassurance that forecast patient demand (and therefore capacity planning) is based on sound evidence. In-built and untested assumptions in conventional planning models often lead to  over-sized health facilities that are uneconomic and provide a poor return on investment. In a changing context such as this, the failings of established current practice are readily exposed.

Our latest project therefore has importance well between the borders of Sweden. It will not only inform emerging best practice, but provides a valuable case study that leverages established technologies in a new form of analysis.

Dr Matthew Bacon has been working with the Schools of the Built Environment, School of Nursing, Midwifery, Social Work & Social Sciences, and Health Sciences at the University of Salford to develop a unique Masters degree module in Architecture and Wellbeing.  Bacon has long held the view that a rich ground for innovation can often arise at the interface between very different professional disciplines. This has been the foundation of much of the work in The Conclude Consultancy (TCC).

In their drive for low energy hospital performance, TCC has identified the compelling need to develop the skills required to translate the needs of clinical professionals into requirements for hospital planning and engineering design. However, this is not a ‘one-way’ process, because planning and engineering teams can add much value in a challenging process and so the need is to translate opportunities into the impact on clinical space, environmental strategies and of course clinical delivery processes. Innovation works both ways.

However, it is a sad reality that few professionals are either equipped with the knowledge and expertise needed to facilitate such a dialogue. Few are equipped to understand decision-making processes in either domain (architecture) or health (wellbeing) and how one potentially impacts the other. As we drive for challenging targets in low energy performance  in the built environment it is obvious that buildings of the near future will have to be very different from those of today – but at what cost to the user and user wellbeing?

This programme is designed to answer questions such as these. It is designed to educate a new generation of post-graduate architects, engineers and health professionals in the practices necessary to create an integrated process where they learn the skills necessary for effective communication, decision-making and requirements management. The programme will bring together clinicians and health professionals from the Nursing leadership management programme with the Architecture and Wellbeing programme into a collaborative environment where both set of students work together to solve classic issues of contemporary hospital planning and design.

Please do contact us through our contact page or alternatively, Prof. Oren Lieberman at the University of Salford (o.r.lieberman@salford.ac.uk), should you wish to find out more about this exciting offer.

It is perhaps ironic that hospitals as caring institutions, are one of the most energy intensive building types, yet have the greatest potential to do harm to the environment. It is lamentable too, that the overall hospital energy performance of hospitals has hardly changed in two decades. This is why fundamental change to hospital planning and engineering design is required. The Conclude Consultancy are operating at the forefront of that change and in this regard we can announce that we are to be working in Sweden with the Gothenburg regional administration on a pilot project for a new 30,000m2 women’s hospital – focused on achieving a new benchmark in In-use energy consumption.

The administration recognises that control of In-use energy consumption is a major challenge in driving for Near to Zero Energy Buildings (NZEB’s). This is a definition under the European Building Performance Directive that requires all new public buildings to achieve near to zero energy consumption from 2018 onwards.  The challenge is made all the more difficult because a European Union (EU) study carried out in 2012/13 identified that the growth of In-use energy in buildings has effectively nullified all gains made through improved thermal and engineering systems performance. This was referred to as the ‘activity effect‘.  In other words it is the growth in electrical energy consumption caused by the building occupants activities that has largely led to this situation.

In Sweden, which has one of the most advanced NZEB strategies in the EU, they have progressively reduced thermal energy consumption to amongst the best in the EU.  They now recognise the need to focus on In-use electrical energy consumption and to make a substantial impact on the ‘activity effect‘. This is why the Gothenburg administration has decided to engage with Conclude, who will guide them to achieving Near to Zero Energy Hospitals performance.  Conclude will be using their unique OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling methods to inform the optimised planning and design of engineering systems. Working with the clinical leadership team, Conclude will be identifying the major causes of energy consumption associated with each clinical pathway for the different types of patient using the services of the hospital. Our unique methods provide detailed insights as to the operational practices that can be streamlined to drive down In-use energy consumption.

Readers of this article might ask the obvious question – “well doesn’t it stand to reason that there has been a growth in hospital energy consumption – after all with all the additional equipment and people is it not inevitable?’  Of course this is a reasonable point – that is until one discovers just how much energy is wasted and that clinicans have very poor understanding of why and when this situation arises.  This is the work of Conclude: To analyse, to inform, and then support better decision making in the pursuit of optimised energy performance.  The opportunity is to reduce In-use energy consumption between 30- 50% and yet improve hospital capacity by making it more efficient AND improve the patient experience at the same time!  These are the possible win – wins of hospital operations today – drive down the cost of operation and drive up service performance.

Please do contact us through the contact form should you wish to learn more.

Earlier this summer The Conclude Consultancy was appointed by Brighton & Sussex University Hospitals NHS Trust (BSUH) to carry out an analysis of In-use operational policies and working practices that impact energy consumption and carbon emissions across their health care estate.  Conclude were appointed by the Trust because of the unique methods that they developed, known as OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling. It is through these methods that the energy and carbon impacts of operational policies and working practices are analysed.

BSUH Assistant Director of Estates and Facilities, Mr Des Weeden said: “We are currently engaged in the planning of an Energy Performance Contract with one of the UK’s largest ESCO’s, and in that work we have identified that operational risks have the potential to negatively impact the contract. We believe that the highly innovative methods developed by Conclude will enable the Trust to effectively manage those risks.  The consultancy has developed a means of holistically modelling the whole hospital operations and to directly corrleate these to the energy and carbon impacts of those operations.”

Dr Bacon adds: “The usual concern of the ESCO is that operational practices can undermine any M&E plant infrastructure improvement programme, such that the forecast benefits may not materialise.  Currently ESCO’s often manage these risks through what can amount to substantial financial contingencies.   However, research from Europe finds that without addressing the underlying operational causes of energy consumption, then these risks are likely to be endemic in many energy performance contracts within the health care sector. Thus the objective of our analyisis is to expose those underlying causes, and so enable the associated risks to be managed through clinical service optimisation or redesign.”

An important part of the method that Conclude has developed is a model of each ‘patient pathway.’ This is a view of the clincial pathway, but it is modelled in conjunction with the physical pathway through the functional spaces of the hospital.  A temporal dimension is added to this model so that the forecast energy impacts can be analysed. Conclude has found this a particularly effective means of developing a dialogue with clinicians, so that as these pathways are investigated, the underlying energy impacts are exposed.

The Conclude Consultancy has recently completed a fascinating study into the energy modelling of patient pathways. We believe that this work will make a significant contribution to understanding how energy is consumed in complex facilities such as acute hospitals. We believe that this will be the case because we have succeeded in directly correlating the energy impacts of use to each patient episode within any part of the hospital.

Why is this important?

It is important for a number of reasons. Firstly because current norms of energy consumption are usually based on building area and volume. So typical norms are: kWh/m² or GJ/100m³ . Many of the standards used in health care facility energy performance use these norms. Yet they can be both very misleading as well as potentially irrelevant to the needs of a clinician who might just be interested in how they personally or how their department could improve energy consumption. Such norms are misleading because they do not reflect intensity of use. For example for the energy conscious clinician when they see that despite the results of their efforts consumption actually goes up, would that not be a little deflating for them? Perhaps the reason for the increase in consumption is because the number of patients processed through the department has risen, and perhaps it is that increase which has caused the increase in consumption?  This is what we mean by intensity of use: more patients per hour, per day, per month for example.  Perhaps it is the difference of intensity of use between UK hospitals and those in Europe that explains why UK hospitals do not appear to perform as well from an energy consumption perspective?

Figure 1. Intensity of use. [Source: http://www.hope.be]

In Figure 1 we can see (if you click on the image it will enlarge) that France and Finland for example have similar intensity of use, but the evidence is that their acute hospitals appear to perform  better than the UK from an energy performance perspective. In contrast Swedish hospitals appear to perform much better than the UK hospitals, but then they have much lower intensity of use. So if intensity of use might partially explain the difference in performance (all supposing we are comparing like for like) then what are the other factors that drive energy consumption and how might these be controlled?

This leads is to the second point as to why area or volume based norms are misleading. It is because of this – that unless the clinicians can be presented with concrete evidence to explain how their working practices impact energy consumption, then they are unlikely to appreciate the need for change. Consequently area or volume based norms mean little to them, because they are intangible measures unrelated to their work.  However, by correlating their working practices directly to patient centric energy consumption, then compelling evidence to support the need for change can be provided.  We mean by patient centric energy consumption that energy consumption is directly correlated to each patient episode for each patient type. It follows that the energy needs of different patient types will vary according to the demand for clinical services of that patient type.  Clearly a patient requiring a video fluoroscopy will consume more energy in their episode than an orthopaedic patient having a plaster cast removed. Furthermore, studies in the United States have demonstrated how different x-ray equipment can impact the working practices of the clinician and yet have very different energy consumption profiles. Both the studies that we have been involved in and the research that we have undertaken have demonstrated much potential for control of energy consumption through analysis of working practices and operational policies. This is the evidence that clinicians require to start to see the need for change.

How did we carry out our analysis?

We have developed two forms of analytics: OCCUPANCY ANALYTICS ™ and Whole Facility Energy Modelling. (Please refer to the Conclude Process at the bottom of our web page). By taking a whole systems perspective of organisational processes and energy modelling focused on patient demand, we have been able to understand the impact of working practices and the energy impacts of those practices from different perspectives within the organisation. For example we can study consumption from a whole hospital perspective, but we can also study it from a departmental, or specialist function perspective. Yet we can also study it from a patient perspective.  We have been able to achieve this because we understand the statistical probability of where each patient type will be in the hospital at any hour of the day. We also understand the energy consumption within each part of the hospital at each hour of the day, and thus by modelling these two datasets we can forecast the statistical probability of energy consumption for each patient type for each patient episode at any period of the day.

Figure 2. – Energy consumption probability profile for a Nuclear Medicine outpatient appointment

How does this help the clinician to understand how they could influence energy consumption?

Because we use the documented working practices and operational processes as the basis of our simulation (quantitative analysis) and so provide the evidence to explains the impact on energy consumption. We then work with the clinicians to consider ‘what-if’ scenarios where we consider the energy impacts of different working practices and operational policies.  We discuss the issues and the challenges and in doing so establish a clear context for improvement (qualitative) analysis.  It is through this process that clinicians are empowered through learning – learning about how to they can impact energy consumption – consumption focused on each patient pathway through the organisation.

It is through this learning that clinicians can also start to understand how the control of patient flow impacts energy consumption, because flow impacts the demand on the environmental systems that provide occupant comfort. As flow becomes interrupted it places larger demands on those systems – a demand which drives energy consumption.  In Conclude, we argue that if we can improve patient flow – we can also improve energy consumption. In fact we can also impact the sizing of the engineering systems, which drives down the capital cost of them. Effective management of patient flow impacts not just the patient experience (reduced waiting times for example) but improved energy performance.

It is for all of these reasons that modelling of patient pathways offers many benefits, and not just providing visibility to the factors that drive energy consumption. It also becomes a valuable means to bridge the divide between the coupling of hospital engineering design with In-use working practices, and that must be a good thing.

Our latest referreed scientific journal paper has just been published by Taylor and Francis in a special edition of the Architectural Engineering and Design Management Journal: The Impact of the Building Occupant on Energy Consumption.

It can be downloaded for free here: http://www.tandfonline.com/eprint/RTGSmimUqH3cgMI9TaTs/full

The paper explains the science behind OCCUPANCY ANALYTICS ™.  It also explains the impact of this work on the low energy – low carbon performance of a major new hospital in the UK.

We are currently writing another scientific paper that explains how this work has been developed to model the energy and carbon impacts of each patient pathway through an acute hospital facility. We believe that this work will also make a significant contribution to low energy – low carbon hospital design and operation. This is because, (for the what we believe will be the first time) it will be possible to transparently model the impacts of clinical working practices on energy consumption and carbon emissions for each patient type on each pathway. We believe that this could provide the basis for new norms for the measurement of energy and carbon performance, founded in OCCUPANCY ANALYTICS ™.

Should you wish to receive more information about our research in these areas please do use the contact form here: http://www.conclude.org.uk/contact/

Professor Bacon has just returned from CleanMed Europe where he presented our latest work on the energy and carbon analysis of patient pathways in acute hospitals.  For those readers who are unfamiliar with this concept, it is a means for analysis of the patient journey both to and through a hospital, as well as the return journey to their home. Our current focus concerns the journey through a hospital as it relates to each different type of Outpatient visit.

You will find a poster about our work here.

What is the value of such an analysis?  

The simple answer is that it provides the clincians in the hospital with a whole new understanding of how their working practices impact energy consumption and carbon emissions.

But what prevents clinicians from gaining this understanding today?

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The Conclude Consultancy Limited has recently completed a lift passenger demand modelling study for a Lift Traffic Analysis in a major acute hospital in the UK. The work clearly demonstrates the value of OCCUPANCY ANALYTICS ™.

The challenges for Lift Traffic Analysis in hospital design

Conventional practice in lift traffic analysis for hospitals relies on lift engineers being obliged to utilise less than perfect analysis models to forecast demand at each lift lobby in the hospital as well as the destination floors for each occupant. The difficulties of forecasting passenger demand in complex buildings, such as hospitals, has challenged lift engineers for decades.  Experts have developed imperfect models of analysis, but our research has shown that such models are inappropriate to hopsitals, because they have usually been conceived for use in the planning of lift provision in office buildings.  For example, the simulation software that one major lift manufacturer attempted to use in the hospital was to approximate demand by using a combination of shopping centre and office data models. Inevitably the lift traffic analysis has to incorporate many assumptions, because of these imperfect models.

The risk for the engineer is both one of over-sizing as well as under-sizing the lift provision.  Indeed a recent comparative study in Germany found that using conventional UK design guides and an alternative method, resulted in a difference of  two lift banks.  Over-sizing of lift provision can directly impact energy consumption and the associated carbon emissions. It could also lead to much greater capital costs, but the operating costs could be significantly greater too….that is until now.  Conclude’s OCCUPANCY ANALYTICS ™ work provides the science that lift traffic analysis has long sought: the ability to reliably forecast passenger demand and thus ‘right-size’ the lift provision.

Occupancy analytics

In achieving the forgoing, occupancy analytics provides a rich dataset for lift traffic engineers, because it provides a total forecast demand profile for every occupant type in the hospital that would conceiveably need to use a lift. The occupancy data that is produced provides a detailed insight into forecast occupancy flux throughout the whole hospital, resulting in the following reporting:

• Numbers of occupants at each floor level at any minute of the day.
• Occupant pathways and amount of traffic on each for each lift lobby.
• Occupant demand profile for each floor of the  hospital at whatever frequency is required.
• Occupant type profile: Porters, Cleaners, Engineering staff, Administrative staff, Medical staff, Patients and Visitors.

Figure 1 – Example of passenger demand modelling in a hospital

 How has Conclude been able to achieve this breakthrough when it has preoccupied specialists for some decades?  Put simply OCCUPANCY ANALYTICS ™ was conceived to enable a whole hospital understanding of occupancy to use this new knowledge in the analysis of space utilsation, and the energy and carbon impacts of us.  The same data that predicts occupancy at any time of the day anywhere in the hospital can be used to predict occupancy in each lift lobby.  It is because the occupancy profile also enables Conclude to model the physical route of each journey for every occupant type in the hospital that we are also able to provide the detailed data required for Lift Traffic Analysis.  Conveniently, the output has been conceived so that it can be processed directly into a simulation model for Lift Traffice Analysis.

If you would like to learn more about this work, please do get in contact by using the contact form on this web site.

The Conclude Consultancy Limited has been in a dialogue with Health Facilities Scotland over the course of 2012, culiminating in an invitation for Professor Bacon to address their annual conference in November.  A copy of the presentation can be found here:

http://www.hfs.scot.nhs.uk/conference-/conference-2012/programme/parallel-sessions-c/

HFS are very interested in the new building science developed by Conclude called OCCUPANCY ANALYTICS ™. Scotland has an aggressive low carbon agenda and the Sottish government is determined to reduce the carbon impact of the health estate. A report by Davies Langdon last year concluded that the pay-back period for improving the energy and carbon performance of existing buildings was going to run into decades.  Clearly we need to make fundamental changes in the way that we design and operate our hospitals.

Here at Conclude, we believe that the solution to this challenge is by society learning to use it’s built assets quite differently, because it is only through a change in how we use our built assets, and specifically how we change the way that we use our hospitals, can we hope to achieve a the major  reduction in carbon emissions required by the Carbon Reduction Commitment.  It is the results of our work over the last two years that provides us with the confidence to substantiate this belief.  Nevertheless  it remains a significant challenge for Trusts and Hospital Boards in Scotland, England and Wales.  The scale of the problem can be appreciated by reading the Sustainability Development Unit’s 2012 Carbon Footprint report:

http://www.sdu.nhs.uk/documents/resources/Carbon_Footprint_Published_2012.pdf

Note from this report how building efficiency is forecast to get worse.  Indeed in most Strategic Health Authorities in Engand, carbon emission’s have risen over the reporting period.  This should not be a surprise, because the Royal Academy of Engineering commented in 2011 that buildings today perform little better than they did in the 1980’s.  They too lamented the demise of building science. Yet there is an alternative that some have commented is all too obvious: change the way that we operate our hospitals!  Conclude’s work in this area has clearly demonstrated the dramatic effects of changes in both how hospitals are operated as well as how they need to be designed.

Our work has been warmly received by clincians, and when asked why they feel so positive about it, the common answer has been: “for the first time we have real, tangible evidence of the impacts of our working practices”. Our work truly bridges the ‘Great Divide’ between designer and users, and provides the basis for a new dialogue between them. Our work speaks to the clinicians because it is evidence-based, and directly corelates their working practices to energy and carbon outcomes, as well as health outcomes.

Please do contact us to find out more.