Overseeing the Royal Free Hospital’s A&E refurbishment has required Mace to co-ordinate closely with staff as work takes place yards from open heart surgeries.
Project: Royal Free Hospital A&E refurbishment
Client: Royal Free London NHS Foundation Trust
Contract value: £25m
Project manager: Mace
Main contractor: Logan Construction
Start date: December 2014
Completion date: July 2018
Seldom has a Construction News site visit been quite so hush-hush.
As we move steadily from one part of the site to the next, voices are kept low and our tour doesn’t linger in the same spot for long.
The reason is simple: this work is taking place in and around Royal Free Hospital’s live A&E department. Unsurprisingly, a key client requirement is that neither staff nor patients are distracted or inconvenienced by the refurbishment taking place alongside them.
As well as delicate, this project is vital for the hospital. The Royal Free’s A&E wing was originally built to serve 60,000 patients a year and today is operating at around 150 per cent of that capacity. As a result, a major revamp started on site in 2014 covering some 5,300 sq m of the hospital, with the aim of increasing capacity and providing vastly improved facilities.
The changes involved are extensive. Phases that have already been completed involved a new paediatric facility, clinical decisions unit and ambulatory emergency care unit, alongside new staff facilities and new reception.
Elsewhere, new rapid assessment and triage and adult treatment areas have been provided, as well as enhanced imaging facilities.
Today, the project is almost at an end, with completion slated for the middle of July. Three phases remain on site, involving alterations to previously created bays to become ‘clean’ and ‘dirty’ utility rooms, works to adjacent corridor and single bedrooms, the provision of a new access corridor and the introduction of a new phlebotomy room and mini pharmacy spaces.
Now that completion is within sight, how has project manager Mace and its team managed to keep to programme while causing the minimum possible disruption?
Of clinical significance
According to Mace senior project manager Claire Bell, working within a clinical environment is definitely the trickiest aspect of the Royal Free project.
“It’s the biggest challenge, having patients on one side of the hoarding and contractors on the other side,” she says. “We have to manage the expectations of the clinical team, making sure that the clinical routes were as they wanted them to be, for instance.”
As an example, Ms Bell cites the work carried out on the main ambulance entrance to the department. “How we got ambulances through what was a live construction site was a massive challenge,” she recalls. “When we were doing the flooring of the ramp, it was really difficult to make sure that they had access.
Mace Royal Free A&E new emergency department
“But we didn’t actually have to close the doors to the ambulances at any point. We picked a time that we thought would be quiet and we had boards there that were ready. We couldn’t have done it without the clinical team helping us.”
As a result of the complexity and sensitivity of the project, the programme was split into 19 distinct phases, all of which has to be communicated clearly to relevant hospital departments as well as the ambulance service. “We’ve worked in quite a few islands in terms of all the different phases,” Ms Bell says.
“It’s also about the flow of the patients and the staff.
“So, that’s making sure everybody can access all the areas and the communication that goes with that. If an ambulance turns up to site and they don’t know where to take their patient, that is a massive issue. We have agreed routes and there are only certain lifts we can use.”
Working effectively with stakeholders is, of course, important on any construction site. But with patients’ welfare at stake, on an A&E department this aspect becomes absolutely critical.
“We have weekly meetings with the clinical team, but also drop-in sessions for the larger pieces of work that we’ve been doing,” Ms Bell says. “The [hospital] trust has got a resilience meeting that they hold weekly, involving all sorts of high-level people from each of the departments. That’s been really good for us because we’ve been able to talk about things six weeks in advance.”
Maintaining such a high level of communication over a long period is challenging in itself, but is made trickier still by the fact that some of the clinical teams involved have changed during the project.
“There have been quite a lot of changes to personnel in the clinical team and that’s been quite challenging because you build up relationships and then all of a sudden you’ve got new people whose views you have to accommodate,” Ms Bell says.
“If an ambulance turns up to site and they don’t know where to take their patient, that is a massive issue. We have agreed routes and there are only certain lifts we can use”
Claire Bell, Mace
“Also, it’s not just one clinical team you have to deal with; you’ve got lots of different departments. So, for example, you’ve got teams like security, infection control… all these people have to sign things off. It’s all well and good saying we’ve signed off this plan, but when we started four years ago it was a whole different team.”
Given all the stakeholders involved and the inherent sensitivity of an A&E department, the number of times work has had to stop on the Royal Free project has been remarkably low. “The only stoppages we have had were when there were complaints about noise when major surgery was happening on the floors above,” Ms Bell says.
“We’ve had some intricate heart surgery going on when we’ve been drilling into the slab underneath, so we had to stop the work. But I think we’ve only had five or six hours of stoppages this year. You get all sorts of different people calling up.
“Sometimes it’s because they’ve got a headache or maybe just had a bit of a bad day. But sometimes it’s life-critical operations that are happening.”
Which complaints are valid?
The reasons for complaint may vary, but Ms Bell and her team understand that they do not have the clinical knowledge to assess which need to be prioritised. Accordingly, a formal system is in place to assess the merits of each and every complaint.
“We’ve got an escalation process,” she says. “So, generally one of us will go up to site, meet the person who has made the complaint and then it gets escalated up to the clinical director. Obviously, we can’t make a clinical decision and we don’t know what is and isn’t acceptable. So, it’s about making sure that we have the right people on board to make those decisions.”
Mace Royal Free A&E resus and radiology 2011
William Logan, managing director at the project’s main contractor Logan Construction, agrees that the right procedures are crucial, noting that 70 per cent of his company’s work is on NHS refurbishments.
“It’s about the appreciation of the environment that you’re in,” he says. “For us, there are contractual arrangements in place, but it’s also about common sense – about understanding you’re in a sensitive environment. Our chaps are absolutely told to stop on the first phone call. We stop and sit tight for five to 10 minutes while the escalation process goes on, the clinical review is undertaken and then works can proceed.”
The fact that Logan Construction has experience in hospital environments also means it is able to minimise supply chain risk.
“In term of the supply chain, we don’t go outside of our vetted chain,” Mr Logan explains. “It all plays into that approach of appreciating how to conduct a major refurbishment in an A&E environment where things can change very quickly.”
However, it isn’t possible to eliminate all risk when working in such an environment. Mace and Logan conducted rigorous surveys – information from when the building was built in the mid-1970s was minimal, Ms Bell says – but there was only so much they could do while the department remained operational.
“We did our best to look down the programme and de-risk delivery as much as we could,” Mr Logan says. “But going in and cutting out ceiling panels and then putting them back and doing a clinical clean in a short window is just not viable. So there were some elements that just couldn’t be foreseen.”
“For us, there are contractual arrangements in place, but it’s also about common sense – about understanding you’re in a sensitive environment”
William Logan, Logan Construction
One such element was discovered in a former x-ray facility, when the team found lead contamination above a ceiling board. “Obviously, we did all the surveys that we could, but until that x-ray was decommissioned, we couldn’t do any intrusive surveys,” Ms Bell explains.
“We were expecting to find lead in the walls but not necessarily lead dust on the ceiling tiles. That stopped us for 27 days because it’s basically dealt with like asbestos. It stopped all works on site, so it was a bit of a nightmare, but it’s not something that anybody could have foreseen.”
The Royal Free A&E refurbishment is not a massive job in terms of revenue, especially for a company the size of Mace. But contract value is not the only way of measuring a project.
If the NHS estate is to be restored while essential services are maintained, an exceptionally sensitive approach to construction is required – something Mace, Logan and the rest of the team are striving to deliver.