Proceedings of a Workshop
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June 2019 |
Facilities Staffing Requirements for the Veterans Health Administration—Capital Asset Inventory Database Management and Strategic Capital
Proceedings of a Workshop—in Brief
The National Academies of Sciences, Engineering, and Medicine convened a workshop on February 19-20, 2019. The purpose of this 2-day workshop was to explore the tools, techniques, and models being used by the Veterans Health Administration (VHA) and other organizations both within and outside the federal government for facilities asset and data management, capital planning, and project management relevant to Veterans Affairs (VA) hospitals, and in particular the staffing challenges relative to those functions.
Following welcoming remarks and introductions, Committee Co-Chair Ambassador James Smith described the context for the workshop and its charge and introduced the day’s keynote speaker, Thomas O’Neill, national manager, Asset Management, Farnsworth Group, Inc. O’Neill’s primary focus was on “lean principles” for problem solving. Most large organizations face common issues such as insufficient staff, budget, and data. In such an environment, it is key for operations and maintenance (O&M) staff to choose the correct tools to address problems. Rather than reacting to crises as they arise, O’Neill recommends “structured problem solving,” which entails root-cause analysis and an iterative process of “planning-doing-checking-acting” to sustain change.
The process of developing an O&M staffing plan involves five elements that O’Neill termed operations, maintenance, engineering, training, and administration (OMETA). To that end, it is important to thoroughly understand the O&M mission—its customers, activities, values, and performance measures—and the organization within which it functions. O’Neill finds that many organizations have no O&M plan. He described a simple capital planning process that begins with conducting an inventory and assessment of assets and proceeds to an iterative process of developing project requirements and budget, defining deliverables, implementing plans, and then measuring success through frequent audits and continuous adjustment and improvement.
Scott Robinson, director, Facilities and Real Estate, NASA, gave a presentation on staffing for capital project management, based on a recent study of NASA center facilities. One of the main project staffing challenges these centers face is staff reductions due to rapidly changing budgets, pressure to reduce overhead costs, and competition for program-related positions that are seen as more central to NASA’s mission. These reductions lead to decentralized project management across the various sites, which is inefficient and results in a loss of historical knowledge. Other factors that impact project staffing include project size, type, and complexity. Where staffing is higher, it is usually in the design stage of a project. But even when staffing levels are adequate, the loss of a person with key expertise can critically impact performance.
To address these challenges, Robinson recommends hiring to baseline requirements and supplementing as needed with contractor support, establishing a centralized team of design experts, developing nationwide or regionwide contracts, and partnering with other agencies for these functions. He also recommends establishing a formal “smart buyer” program policy and defining key requirements for smart buyers regarding infrastructure, contract methods and processes, technical expertise, and contract oversight.
The second morning session began with a presentation on metrics and data visualization as a tool for managing facilities using real-time data, given by Stefan Komarek, senior leader, Mission Assurance, Honeywell Federal Solutions. A key aim of his talk was to explore how metrics and visual management (VM) relate to lean operating systems (LOSs) and how the two together can drive continuous improvement and assessment, ultimately influencing organizational culture and performance.
Komarek noted that VM is a way of converting data to easily seen indicators of organizational “health.” It begins with key performance indicators, or KPIs (i.e., metrics—as distinct from mere data), which are quantifiable objectives for organizational processes. Careful selection of the metrics is crucial; if, properly chosen and displayed, they are the primary indicators of “core process stability” and can drive the focus of the enterprise on desired actions and behaviors. As a management tool, if the metrics are aligned well with the objectives (both strategic and tactical) of the enterprise and are presented using effective VM, Komarek said they can bring about the desired responses and even change organizational behavior over the long term in ways that produce sustainable positive results.
Key to this desired culture change is the use of VM-based management as a core component of an LOS, which Komarek defined as “the culture of process stability and continuous improvement under an Enterprise Excellence Model.” (The Enterprise Excellence Model, in turn, is “how the entire enterprise integrates and responds to ensure performance” through a continuous, iterative process of planning-doing-checking-acting.)
The ultimate goal of using an LOS, Komarek stated, is to realize enterprise strategies. However, he continued, the real challenge is not just developing an effective strategy but also deploying it. In this connection, Komarek described the SIPOC (suppliers, inputs, processes, outputs, customers) model. The customers, both internal and external to the organization, are the recipients of the process outputs. In a government organization, where competition is not a driver, the way to drive continuous improvement on behalf of the customer is to develop a “bias for change.”
The last presentation of the morning session was given by Mark Kenneday, director, Business Development-Healthcare, Sightlines, on data management of disaggregated facilities information. He began by noting that 84 to 86 percent of the total cost and effort invested in a health-care facility ends up being directed to capital renewal and deferred maintenance (CRDM)—that is, after construction ends. This is why facilities data management is so important. Kenneday emphasized the need for alignment of the following four key aspects of “comprehensive facilities intelligence” (data): (1) facilities benchmarking and analysis, (2) facilities assessment and planning, (3) space utilization, and (4) sustainability solutions.
A fundamental question underlying these elements is, “Why isn’t your operational strategy aligned with your financial strategy—and ultimately the strategy of the institution?” Most often they are not aligned, Kenneday finds.
Kenneday was asked whether his company has identified any metrics on which the VHA should focus in particular. He responded with the example of capital renewal projects, where opportunities can be identified that have immediate impact on the design and safety of patient care—such as data on patient slips and falls in relation to aspects of room design. Certain room design features may have been implemented to save construction cost, but in some cases the total lifetime cost of ownership is many times the initial savings, due to poor safety-related design. Taking available data of this kind into consideration up front is vital. Kenneday reiterated that capital investment decisions should not be made to improve the facility’s performance unless that performance aligns with the organization’s mission.
Following lunch, the workshop reconvened for the afternoon session. Brian Melewski, acting deputy director, VHA Office of Capital Asset Management Engineering and Support, presented the VA’s strategic capital investment planning (SCIP) process. This is a comprehensive, data-driven planning process that is used for all capital construction programs across the VA. It not only identifies but also prioritizes the VA’s infrastructure needs within a 10-year planning horizon. By producing objective planning decisions, it informs congressional decision making. Melewski said that, using SCIP, every VA facility has a current baseline assessment of needs as well as a projected assessment of future needs. When these are compared against established goals, they highlight “performance gaps” in areas such as space, condition, energy, safety, and security—which in turn represent areas requiring capital investment.
The SCIP process involves the use of a range of “decision criteria” that are weighted and applied to projects under consideration to enable ranking them in terms of their importance to the VA’s goals. Melewski described how SCIP outputs are used to formulate a long-range action plan to close performance gaps. The process is, in effect, a decision model that can be applied to business cases (BCs) that are submitted by individual facilities (such as hospitals) through the various VA administrations (such as the VHA) for consideration for capital funding or lease.
The question was asked whether the process of prioritization and selection of projects is transparent, so that facilities engineers can see the decision process, and how much effort is involved in submitting project requests. Melewski said that non-recurring maintenance (NRM) (infrastructure such as renovations and system replacements up to any value) projects are left to the discretion of the Veterans Integrated Service Networks (VISN) level, while major “minor construction” (new space up to $20 million) and “major construction” projects require a business case and are scored through SCIP. Minor construction projects are selected by the Veterans Affairs Central Office (VACO) and major construction projects are selected by Congress. On the VISN level, often the better writers of business cases—the more articulate planners—tend to get funded disproportionately; while on the national level, more objective prioritization and decision methodologies are applied.
This led to a discussion of the use of SCIP. Melewski said that SCIP is inherently a strategic planning tool—a global planning exercise aimed at closing gaps; but it is sometimes used as a tactical tool, to develop the plan. This is a misuse of SCIP that results in planners having to plan the project after it has been funded.
Following Melewski’s presentation, a panel was convened on risk assessment and the management of risk, with two panelists: Michael Chonko, principal, SMRT Architects and Engineers, Government Practice and Energy Group, and Thomas O’Neill.
First, Chonko reported on a multicampus risk mitigation study he led that involved four Boston-area VA facilities. They looked at a variety of vulnerabilities, including weather, terrorism, failing building systems, fire, epidemics, and so on. He showed examples of specific vulnerabilities and potential points of failure in existing buildings, as well as actual damage.
A key part of the presentation was the discussion of communication tools. Chonko displayed a matrix of risk probability versus risk severity impact, with both being ranked on a 5-point scale. Although the ranking could be somewhat subjective, it provides an analytical way to assess risk and assign to each risk criteria ranging from “unacceptable and requires immediate attention” to “acceptable and continually improving.”
The panel discussion began with the topic of VA physical security requirements and the extent to which VHA facilities are in compliance. Chonko said that physical security is an integral part of every study they do and impacts nearly every area of a facility.
The question arose regarding the impact of upgrades and other changes on staffing or workforce needs. Chonko said perhaps the facility needs analysis should always include a projection of needed changes in facility workforce.
In many facilities, the staffing relies on the “tribal knowledge” of older, longtime employees who may not possess the project management skills or ability to input what they know about equipment
and operations into a Building Automation System (BAS) or to prepare an online emergency document. Perhaps if there were mechanisms in place to document this informal institutional knowledge, a more robust process for addressing appropriate staffing, renewal, and training issues would result. Chonko noted that the lack of key skill sets in a facility can, in itself, be considered a security risk.
This led into a discussion with Chonko of whether the appropriate people are being attracted into the facilities career field today. Ambassador Smith pointed out that this is a career field that is still physically oriented, not digitally oriented. This industry is far behind in that regard. An important question is how the O&M program in a facility is set up. Is it oriented more toward engineering and administration or toward doing the actual physical work? O’Neill mentioned that in order to attract younger, more tech-savvy people, systems such as the Computerized Maintenance Management System (CMMS), asset management, and Building Information Management (BIM) might interest a young construction engineer or manager in wanting to enter this field. Outsourcing more of the physical work might be a reasonable option.
Chonko mentioned that the single biggest vulnerability, in his view, is limited resources (in staff time and funding). The prioritization of needs deriving from risk assessment should be part of the capital planning process, with repair and replacement needs understood as evolving continuously over time.
With the conclusion of the panel discussion, a period of open discussion began. Steven Broskey, associate director, VHA, led off with remarks about the importance of integrity and accuracy of facilities data. He believes that it is imperative for all VHA hospitals to have a point person to maintain the data and as-built drawings as “a foundational point of reference,” because inaccurate data makes the gap analyses invalid. Kenneday and Kimon Onuma, president, Onuma, Inc., continued that line of discussion with the observation that it would be a major asset and improvement for all facilities to have a BIM standard. They believe as well that managing the BIM model requires a core staff—and if that is not possible, an outside BIM operator should be engaged.
Brian Yolitz, associate vice chancellor, facilities, Minnesota State University, summed up the day’s discussion by saying that there are several factors driving workload around capital planning, data management, and project delivery. They include size and age of the facility, the condition and the history of its maintenance and operations, and other investments over time. There is the question of whether to insource the work, outsource it, or follow a shared-services model. Reliable ways are needed to define these factors and determine correct actions.
David Alvarez, VHA engineer, said that, in his view, O&M, capital planning, and project capital execution require different staffing models, depending also in part on the size of the facility and its budget. There is also a need for integration of functions—that is, project staff and maintenance staff should interact, with executive oversight. Yolitz concluded the discussion by outlining the ideal attributes of facilities staff: they should be critical thinkers, lean-oriented risk managers with technical savvy, who are customer service-oriented.
Day 2 of the workshop convened with a welcome and plans for the day by Committee Co-Chair James Smith. A panel on capital planning was introduced by Ambassador Smith. First to speak was Lance Marrano, director, Sustainment Management System Center of Expertise, Engineer Research and Development Center, U.S. Army Corps of Engineers. He gave an overview of how the Army does capital planning using the Sustainment Management System (SMS) decision-making process (including the BUILDER SMS module) and their research and development on the Virtual Testbed for Installation Mission Effectiveness (VTIME). SMS consists of separate management tools for different asset types, such as building components, fuels systems, airfields, and roads. They provide facility managers with life cycle management tools needed to objectively assess assets, analyze and prioritize investment requirements, track investments made, and forecast future investment needs through course of action (COA) analysis.
Basically, the Army’s entire O&M planning process starts with a component-level inventory. Rather than relying on expert opinion as to remaining service life, they ask the assessor to report the appearance of deterioration—actual data—and then let the SMS determine the needed repair actions.
Ultimately, this drives an investment plan that is based on enterprise-defined rules that, in turn, generate consistent requirements across the entire asset portfolio. From the headquarters perspective, this system provides transparency, accountability, and traceability.
Marrano said that data analysts are needed who can understand the data and use business intelligence tools like Tableau. Also, training is needed for assessors and facility managers; each user community has different skills and requires different training.
Department of Defense (DoD) agencies are starting to look at “Smart and Resilient Installations (SaRI)” and how these types of capabilities are adapted and applied in the commercial space. They are developing an installation common operating picture called VTIME to leverage cutting-edge capabilities in the information space using big data, predictive analytics, and artificial intelligence, in order to fit the independent models and individual business processes together to produce optimized outcomes in which the whole is greater than the sum of the parts.
The next panelist to present was Onuma. He explained that his company, which consists of architects and software developers, has a unique perspective on dealing with systems, information, and complex environments that they call “building informed environments.” Maintaining current data is key. The challenge, he said, is that the construction industry is second from the bottom in the use of digital data (above agriculture). It relies on a document-file-based approach to sharing information, whereas today’s standard for most industries is real-time data calls using software applications and integrated systems.
By contrast, Onuma gave the example of Amazon. In 2002, its founder demanded that all data—whether in technology, accounting, marketing, or sales—be open, transparent, and universally shareable both inside and outside the company. Today, Amazon has a platform built on shared information, where the data itself is the asset. The takeaway for the VHA is that there is already very valuable information, but it exists in silos; the need is to open it up and share it internally across platforms and facilities.
Next, Onuma talked about the Space and Equipment Planning System (SEPS), which is a system that is jointly managed and developed by the VA and the Defense Health Agency. In simple terms, SEPS allows combining the number of patients, procedures, and authorized staff to yield as a result the amount of space and equipment that will be needed. Onuma also talked about using
Onuma’s company uses BIMStorm(.com), an online training resource that allows the user to input information that is not secure. Users can test data and can actually build the requirements model for a hospital or an airport or an office building and build a BIM system literally in minutes.
The solution that Onuma espouses is not one system—it is about having authoritative source data in one place, with shared services. There are huge risks in data, he said, but if an organization does not approach these risks in a modern way, the risks just keep increasing, because the more attempts that are made to aggregate and connect data, the more risk there is. A seamless system is multiple applications that can talk to each other—there is no single system.
The third and final member of the panel on capital planning was Marc Vandeveer, chief innovation officer, U.S. Air Force Installation and Mission Support Center (AFIMSC). Vandeveer introduced the Installation Health Assessment (IHA), a framework to deliver installation and mission support (I&MS). IHA takes into account all of the portfolios within the AFIMSC, not just construction and maintenance, but also service members and family services, security, communications, deployment, and distribution. They are “on the cusp of moving this into the cloud” and developing the capability to offer the software as a service.
Vandeveer showed some example charts in Tableau that displayed the status of infrastructure for different services. The data come from the SMS systems, specifically from the BUILDER and PAVER software modules. Each pixel in the chart (over a million per slide) is clickable and its color shows the
current condition of that item. Scrolling with the mouse over any pixel displays a tooltip with in-depth information about that item. Vandeveer then showed a single chart with an overview of the entire I&MS enterprise. By using Tableau and tying all the databases together, mission performance can be shown. The ultimate goal is to merge performance, sustainment, and modernization costs and risks for the entire portfolio.
Vandeveer was asked if individual wing commanders will feed their data up through the chain of command so that everyone is looking at the same data. He replied that they will have Tableau servers in the government cloud space, with mirror licenses and creator licenses so that people can view or manipulate the data at the Headquarters Air Force, Major Command, and installation levels.
The day’s keynote presentation, “Transforming Healthcare Facilities Management: A Pathway Forward,” was given by Clayton (“Mitch”) Mitchell, vice president, National Facilities Operations, Kaiser Permanente (KP). Mitchell described KP’s move from a capital-centric model for maintaining and sustaining their facilities to a total life-cycle facilities model. They have a variety of goals, including increasing useful facility life from 40-50 years to 100 years. They would like to begin to deliver a “true enterprise approach” to systematizing the management of plant assets. And they want to achieve total asset visibility as to cost of service, financial reporting, and infrastructure portfolio performance.
Mitchell’s brief included business plan development for the facilities operations enterprise shared service (one of 22 enterprise shared services). Focus areas that they are addressing include enhancing the brand, readiness of the built infrastructure, operational functionality, and the reduction of total ownership costs leading to better affordability. They are aiming at a 2020 rollout of an enterprise portfolio strategy for improved integration between capital renewal with preventative maintenance and restoration across all of their eight regions.
Mitchell believes that KP’s required operating capabilities fall into three categories: extracting greater value, developing an enterprise delivery system that can provide a better business focus in how they deliver services, and affordability. To achieve those capabilities, they are driving toward a “transformation strategy” that has five “key pillars”: (1) governance, (2) process standardization, (3) workforce development, (4) technology, and (5) strategic sourcing.
In adopting their new “Total Lifecycle Management” focus, Mitchell said that KP would like to end up with a situation in which 90 percent of services delivery is standardized and 10 percent is left to the discretion of the individual facility. A core principle is a common portfolio strategy in which managers understand that in every building they build, they will align around common protocols and communications for building management systems.
Mitchell noted that today, KP has a nonintegrated management system. However, they are driving to develop an integrated management system, in which systems, processes, and workforce capabilities are fully integrated and subject matter expertise is leveraged across the enterprise.
Taking questions, Mitchell was asked what kind of staffing would be needed at medical centers to coordinate both infrastructure- and renovation-type construction projects. Mitchell replied that, given intense competition in KP’s industry, they try to keep a cap on full-time employees (FTEs), so their intention is to use their in-house FTEs at a higher level of capability to meet new demands for strategic, client relations, and program management capabilities.
This discussion led to the question of how KP obtains buy-in from their doctors on these efficiencies, which result in changes in their mode of practice. Mitchell said that market stressors have helped to convince them they are necessary. Medical group leaders in particular understood the need and led the changes.
The question was asked, “If I pick up my iPhone and ask Siri, ‘What’s the weather like today?,’ it will tell me. How far are we from being able to ask, ‘What’s the status of my boiler?’” Mitchell replied that every KP building has an automated building management system (BMS). Only about 7 percent are networked together. The goal is BMS integration across the enterprise. He thinks it is possible to go from 7 to 100 percent in 5 years (roughly the refresh time for any building automation system BMS).
Next on the agenda was a panel on managing project delivery. Robert Anselmi, chief engineer, VA Cheyenne (ret.), introduced the three panelists, beginning with Patrick Duke, managing director, CBRE Healthcare. Duke explained that he would talk about a general approach to project delivery, an effective way to launch projects, and what staffing ratios are in health systems across the country. He said that the health-care industry has not yet begun to “shed the weight of their assets through creative ways,” as other industries (such as hospitality) have. Savings are looked for only in the design and build phases; the back-end life cycle costs (representing 87 percent of the total) are difficult to reduce. He contends that if more is spent on smart design in the capital expenditures phase, the overall “whole of life” costs will shrink.
Duke defined optimal project delivery, which has three basic elements: it is outcome driven; it has to embody effective risk transfer; and it has to be culturally supported. The organization’s culture is a by-product of the environment in which it exists. But the environment should not be an inhibitor; it should be a catalyst for creativity. However, changing culture in big organizations is extremely difficult, he observed.
Launching a project starts with outcomes. Duke’s company starts every project with True North (a key concept in lean process improvement). This process translates outcomes into action by defining outcomes, behaviors, and metrics of success. Then they develop a project implementation plan, broken down according to its elements. From there, they develop team playbooks, based on a standard playbook customized for the type of project.
The most important step, Duke said, is integrated process planning. This is a lean-led design involving simultaneous process design, space programming, and conceptual design—all developed by the entire project team along with the stakeholders.
Duke presented a detailed list of elements that must be managed in each phase of a project, from strategic planning through design and construction to activation and occupancy. (Facilities maintenance follows.) For capital project delivery teams to be successful, they should be involved in all phases and all should be managed in an integrated fashion.
Last, he contrasted three industry models for project management: insourced, leveraged, and fully outsourced. In the insource model, all project planning and management are done in-house, including early design and inspection. Only design as a production element and construction as a production element are outsourced. He sees that less commonly now.
What he sees most is a leveraged model where the client will manage projects, but will not do any planning, programming, design, construction, inspections, medical equipment or technology, design, and delivery. The client will maintain a core group that will manage the project day-to-day. This model works well. The third model, in which the entire project is outsourced, gives the client variability from year to year in what they can tell the contractor to staff for.
The direction that Duke sees project delivery going in health care is toward viewing their facility as a service rather than as a hard asset. That leads to the concept of performance-guaranteed facilities (PGFs), using managed equipment service models. In that model, the hospital basically monetizes its assets and their life cycle under performance contracts, which allows the hospital and the health system to focus on day-to-day management of what they do—patient care.
Duke was asked to elaborate on what a project manager does, especially in the totally insourced model (which most VA hospitals use). He replied that the project manager coordinates all the upfront design, the programming, and the hiring of the team. They review invoices and they work in the field. They hold the architect contractor coordination meetings. But they do not do any inspections.
Lisa Cooley, director, Federal Solutions, Gordian, was the next panelist to speak. Cooley’s presentation was on job order contracting (JOC) and other methodologies for the execution of primarily NRM work. She began by noting that small projects greatly outweigh, both in number and value, the minor
and major projects, based on the SCIP process. Such projects are a very important component of the VHA s project portfolio.
JOC is one of several project execution options that the VA and other public owners have; others include the indefinite delivery/indefinite quantity (IDIQ) contract, single award task order contract (SATOC), base operating services (BOSS) contract, service-disabled veteran-owned small business (SDVOSB) award, multiple award task order contract (MATOC), and multiple award construction contract (MACC). Major projects are more appropriate for design-bid-build, firm fixed-price contracts. MATOCs are also very popular for the execution of larger projects. Cooley said that JOC shares features with integrated project delivery (IPD) and other performance-based contracting methodologies, but is uniquely suited to the smaller projects as a long-term contract.
Cooley outlined the key characteristics of JOC. A unit price book governs pricing. At the outset of a long-term contract, a multiplier is applied to all of the unit prices. This is a major consideration, since the contractor has now effectively set the price of every imaginable component of construction at the outset of the contract. A JOC is a long-term contract with a potential for very significant volume of delivery orders, but that is not guaranteed. There is an incentive to perform well to get to more delivery orders and to ensure that the option years are executed.
Cooley explained that what makes job order contracting unique from other IDIQ methodologies such as MATOC or MACC is that it is a single award. Rather than having a competitive pool that competes on each task order, you have a contractual price basis in the form of the unit price book and a coefficient so that the contractor and the owner can collaboratively scope price and execute the work. At the delivery order level, it is a single award process.
There are a considerable number of benefits of using a JOC. They include faster project delivery; streamlined engineering and design efforts (which clearly has implications for facility staffing); an assurance of reasonable cost; better contract performance (primarily because of the long-term partnering relationship and the incentives that are inherent in JOC); increased opportunities for local/small/disadvantaged business through subcontracting opportunities; and last, the effective use of year-end funds.
Cooley noted that a major finding is cost savings, reported by both owners and contractors. Contractors are saving on overhead. Owners are saving on administrative costs, especially in procurement administration time, because only one contractor is being procured and then there is a much-expedited delivery-order procurement process. There are savings in project manager support time and reductions in design and drawing costs. JOC should never circumvent needed design, Cooley said, but some elements of design are geared to having a set of bid documents that a group of contractors can bid apples-to-apples on.
On the contractor side, three-quarters of contractors say that JOC reduces their cost in acquiring and bidding new projects. Contractors can instead focus their attention on executing the work successfully for the owner. Last, there is reduced overhead because contractors are working more efficiently. They are working at a single facility or in a single region and can plan the workload with the owner and execute the work more efficiently.
What Cooley’s company found from surveys of the VA community at the station and VISN level and from other customers is that “JOC works, but it does not work for us. It is broken. We will never do that again.” Their VA contacts said, “Our contractors do not understand JOC.” In some cases, they heard contractors say, “The VA does not understand JOC.” Clearly, there is a disconnect.
Cooley made four suggestions for optimizing unit price contracts within the VA. First, adopt a more programmatic approach. Second, leverage enhanced unit price data for more accurate costing, reducing friction in the process. Third, enable technology better. And fourth, embrace and improve the SDVOSB support role.
Data governance is important, Cooley said. That means having a clear set of rules for how the data is used, that everyone can refer to, to reduce negotiation friction at the task-order level. Technology
enablement allows for the management of vast cost data sets. Technology enablement combined with the programmatic approach also allows for analytics, benchmarking, and integration.
The final panelist was Michael Zanghi, director, Facilities, Highland Hospital, University of Rochester Medical System. Zanghi noted that the objective of his talk was to take the “big picture” presented so far and bring it down to the engineers’ level and focus on how to support them in their endeavors—in particular, from the standpoint of project management automation.
Zanghi contends that construction is far behind most other industries in its use of systems and automation; project management is still done using Microsoft Excel spreadsheets, e-mail, and so on. Managers need to start doing project management in a coordinated way—not just in scheduling. Further, the project management software must serve as a platform for all project information. Owners have a wide range of information needs, including the management of vendors, documents, and changes.
Zanghi outlined the main functions of the project platform. For documentation, this platform would include providing a single source of information that is available to all project participants, with security based on role, and with full documentation of communications. As to processes, he said that the software must capture organizational standards and rules consistent from project manager to facility and from facility to facility. It should route tasks automatically from person to person, and then document those actions, time stamping them and reporting on them to ensure that they are done in a timely manner. Platform connectivity across all participants in the project, internal as well as external, and across all the systems (financial, capital planning, and purchasing), he noted, is essential to project management automation.
A well-designed, optimally functioning project platform can provide several important benefits to an organization such as the VHA. First, it can reduce labor by greatly reducing the physical paper handoff from person to person. Second, it can focus staff time on higher-value activities.
A third benefit, risk reduction, is not just a security issue, but encompasses the risk of losing documents, enforcement of policies, and ensuring that data are kept up to date equally for all participants. Last, better compliance with organizational standards and processes helps to ensure that people do not deviate from policy or even from established best practice.
Ambassador Smith then gave his concluding remarks for the workshop, which he had prepared in collaboration with other committee members and the Board on Infrastructure and the Constructed Environment (BICE) director. These observations were organized in terms of key themes. The first group of themes addressed continuous improvement and lean techniques. It was observed that successful organizations employ continuous improvement processes. Accordingly, the committee should consider the overall staffing requirements to support a culture of continuous improvement. This includes consideration of the best tools and technologies for collecting and managing accurate data and measuring facility performance. But before an organization can implement continuous improvement, it is necessary to maintain organization discipline across facilities.
The importance of reliable, usable data on capital assets cannot be overemphasized, Ambassador Smith said. Reliable, accessible data will support the investment decision. This moves an organization in the direction of an enterprise portfolio strategy, where data is an asset. Consideration must also be given to the best ways to present the data, both at the VISN level and to senior management. Visual management on the health of each VISN is a potentially powerful management tool. If policy making is to be centralized, all parties have to be seeing the same data.
Relevant enterprise-wide KPIs can include space (density, utilization, functionality), throughput (admittance, number of patients, room turnover, scheduled medical procedures), operations profile, capital profile, and campus profile.
There is a growing trend, in facility project management, to include more tools and systems that support integration of data. Where data integration has been successful, there is a reduced burden on the facility workforce for data entry. With less data entry, there are fewer human errors and so potentially less work, better data, and better system performance.
The VA’s SCIP process is a well-conceived, bottom-up rollout of investment needs. It accurately reflects requirements within the VHA as built by the VISNs. The question is, does it accurately reflect the state of overall enterprise health? It will be important to build on SCIP in moving to a higher level, at which such things as staffing shortfalls at small VISNs and the density and age of facilities are taken into account. One thing to note is that the quality of writing may in many cases influence decisions based on SCIP business cases more than the actual facts on the ground do. Smaller facilities tend not to have the depth to compete well for projects. If there is technology that allows that process to be simplified, in a building block approach, then it will not only save staff time, but it would also make the smaller facilities more competitive.
The SCIP process does require staffing time, mostly in the local business case development. It appears that there may be an opportunity to capitalize on technologies that reduce the staff time necessary to build cases at the local level. Alvarez noted that decentralized organizations tend to lack the business acumen that facilitates communication with contractors. If the organization is going to evolve to an enterprise architecture and process, it might be useful to have a “relationship manager” at the unit level.
Mitchell commented further that three things are important in facilities staff: capacity, capability, and “coachability,” with the latter being perhaps the most important—that is, the ability to bring new ideas in terms of how to do the work and how to deliver that business acumen into the space. For all staff, being adaptable and learning and understanding the environment one is working in and how to meet the mission goals are vital.
Zanghi pointed out that design considerations are important. Sustainment of some designs involves excessive work and cost. The skill sets needed to sustain the constructed facilities should be considered when major (and some minor) construction is undertaken—not just the personnel to oversee the project, but also to maintain it once it is commissioned. If contract personnel are going to maintain the facilities, then procurement or contract oversight personnel from the VA need to be involved as well to ensure that adequate maintenance is done.
Ambassador Smith said that the biggest challenge for an organization moving in the direction of open architecture is defining what the architecture should look like, as opposed to trying to find a certain vendor that will provide capability.
The contracting issue pertains to staffing in several ways, Smith said. If the VHA were to embrace JOC, some opportunities for reducing workload would be created, increasing the number of contractors available who can do the work and streamline the project management process. The decision of whether to insource, leverage, or outsource is a policy issue for execution at the local level.
Alvarez said that the VA is exploring the use of BUILDER. He made two points about it. One of the VA’s challenges in implementing BUILDER is that, since the VA is not a top-down organization, they could get good data integrity initially, but the challenge is how to maintain that data in a bottom-up organization. He agrees with the need for visibility as all the data rolls up, but expects a greater challenge in terms of data being up to date as time moves on. The second point is that “You have to know how the numbers were put in to begin with to know how they are rolled out.” He said that a program such as BUILDER allows for flexibility in using the numbers one way for a local work order versus another way for a capital investment.
Alvarez noted that there is a difference in the way organizations such as the Defense Health Agency and the VA look at BUILDER. DoD appears to look at it more from an overall building health perspective. The VA focuses more on the health of a particular program—for example, “How is my equipment supporting my inpatient operating room program?” The VA may take a nonstandard approach and develop BUILDER for other types of uses. They are exploring that and are planning a pilot study as they contemplate enterprise-wide adoption of BUILDER. If adopted, it would replace their existing facility condition assessment program.
Ambassador Smith thanked all the meeting participants and the meeting was adjourned.
DISCLAIMER: This Proceedings of a Workshop—In Brief has been prepared by Court Lewis as a factual summary of what occurred at the meeting. The committee’s role was limited to planning the event. The statements made are those of the individual workshop participants and do not necessarily represent the views of all participants, the planning committee, or the National Academies. This Proceedings of a Workshop—In Brief was reviewed in draft form by Robert Anselmi, VA Hospital Engineer (retired); David J. Nash, Dave Nash & Associates International, LLC; and Gary Thompson, North Carolina Geodetic Survey, to ensure that it meets institutional standards for quality and objectivity. The review comments and draft manuscript remain confidential to protect the integrity of the process. All images are courtesy of workshop participants.
PLANNING COMMITTEE: Robert Anselmi, VA Hospital Engineer (retired); Gene Hubbard, RiVidium, Inc.; Kim O’Keefe Former Director for Resources Office of the Assistant Chief of Staff for Installation Management, Department of the Army; James Smith, U.S. Ambassador (retired); and Brian Yolitz, Associate Vice Chancellor for Facilities, Minnesota State College and University System.
STAFF: Cameron Oskvig, Director, Board on Infrastructure and the Constructed Environment; Erik Svedberg, Senior Program Officer, National Materials and Manufacturing Board; Joe Palmer, Senior Project Assistant, National Materials and Manufacturing Board; and Daniel Talmage, Program Officer, Board on Human-Systems Integration.
SPONSORS: This workshop was supported by the Veterans Health Administration.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2019.
Division on Engineering and Physical Sciences Division of Behavioral and Social Sciences and Education
Copyright 2019 by the National Academy of Sciences. All rights reserved.
