Syed Mahmood Akhter

While speaking at a healthcare facility planning and management event organised by Informa Middle East in Dubai, UAE, last year, Syed Mahmood Akhter – then an MEP Consultant and a Functional Manager at Zuhair Fayez Partnership Consultants – recounted a meeting with a client, who put forward the following request: “Don’t design me something I can’t build, and don’t build me something I can’t maintain.” The request left such an impression on Akhter that he has grown to regard it as the best piece of advice he has ever received in his professional life, and has even used it as the title of his presentation at the event.

Building on the client’s statement, Akhter shared figures he said proved how costly downtime in hospitals can be, and how the problem can, in the end, be traced to flawed MEP design and maintenance.

“In the United States, hospitals lose close to USD 2 billion a year because of downtime, with the highest cost for a single instance amounting to nearly USD 1.8 million,” he said, and explained, “Almost two out of five global healthcare organisations have experienced an unplanned outage in the past 12 months at a cost of USD 400,000 per incident.” Such outages, he noted, also lead to data centre losses and security breaches, and revealed: “Nearly one in five of global healthcare organisations have suffered security breaches, at a cost of USD 800,000 per incident. And nearly one in three of global healthcare organisations have experienced data loss in the past 12 months, at a total cost of nearly USD 1 million per incident.”

While they are huge numbers, Akhter pointed out that they weren’t the biggest concern when it came to the issue of downtime in hospitals. “They are just dollar amounts,” he said. “If we don’t avoid downtimes, they can result in something worse than monetary loss. They can cost lives. And that ought to tell you how critical MEP is.”

Hospital rankings, from cancer to urology centres, are determined by their structures, processes and outcomes

Pointing out that, in construction, 45% of the overall cost was MEP, Akhter said: “It’s the single largest block of cost, and this block determines the patients’ comfort and satisfaction and determines the physician’s preference to use your facility. If the physician decided against using it, then of course, no patient would come to your hospital. So, it affects your bottom line and affects your ranking. Hospital rankings, from cancer to urology centres, are determined by their structures, processes and outcomes.”

Drawing from his own professional experience, Akhter identified various examples of causes of downtime, including non-compliance of design codes – breakers and electrical panels exposed to water, for example – and improperly designed mechanical rooms resulting in roof-mounted chillers malfunctioning due to leakages or burnt compressors. He recounted that in one particular case, he was shocked to discover that a technician, in trying to fix malfunctioning chillers, had installed air coolers to blow cold air on the equipment. He further reported that in many instances, chillers are housed in temporary roofed structures to minimise direct exposure to the sun, with car radiators surrounding them to reduce ambient temperature, but that these structures, while intended to be temporary, go for many years without being replaced, repaired or even maintained.

Lack of maintenance could be a result of various factors, but one that he has often encountered is – again – poor design, Akhter revealed. “I’ve seen switches hidden behind pipes and non-weather-proof cable trays, creating potentially hazardous conditions,” he said. “I’ve also seen corridor passages that are too narrow or too low to allow access. In some facilities, catwalks are not available, making it hard for maintenance personnel to access critical valves or expansion joints, which do develop leaks. And lack of access for maintenance means higher risk of downtime and higher operating expenses or even huge replacement costs.”

To avoid downtimes and their resulting costs, he recommended going back to the advice he received from the client, with an added injunction: “Don’t develop a design that can’t be built and don’t build a facility that can’t be maintained, because when you do, it’s as good as robbing the client, as good as robbing the patients.”

The costs of proactive solutions are nowhere close to the costs incurred as a result of poor design

Citing from his experience, Akhter narrated: “I was once approached by a client for a project, and during a meeting with the team, they showed me pictures and I asked: Where are my electrical and mechanical rooms? And the constant answer that I got from the architects was that they would figure it out afterwards. I said, ‘What do you mean you’ll figure it out afterwards? That’s 45% of the cost. Why don’t you figure it out now?’ I know why, of course, because that’s how they approach a project. They want buildings to look beautiful.”

Though Akhter said he understood where they were coming from, he believed that MEP issues need to be addressed up front, and this, he stressed, can only be done if players changed their attitude.

“Start with your approach to building your healthcare facility,” was Akhter’s advice. He elaborated: “The costs of proactive solutions are nowhere close to the costs incurred as a result of poor design. Everything should be in proportion, right? The cost of our fee is in proportion to the cost of construction. It’s this simple: I’m not asking you to raise your cost; I’m asking that you have a different attitude. Go and select the architect. Go and select the engineer. When you select the engineers, ask them beforehand what they plan to do; what problems they’ve had and what they did to resolve them. And remember, cheaper is not always the best choice. Bigger is also not always the best choice. Size matters, yes, but what matters more is the quality of the people working with and for you. Hire the MEP contractors separately. Don’t be victims of flawed design and inferior workmanship.”

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Complex systems are not the answer

On the sidelines of Informa Middle East’s Building Healthcare Exhibition and Conferences, Syed Mahmood Akhter shared with Climate Control Middle East his insights on, among other things, the mega healthcare projects in Saudi Arabia and the concept of value engineering. Here are excerpts from the interview…

As someone coming from the MEP sector, where would you say is the Middle East’s healthcare industry at the moment?

I think, technology-wise, the healthcare industry has come a long way, especially when compared to how it was when I designed my first healthcare facility in Riyadh, back in 1987, if I remember correctly. We did not have these many choices when it came to technological solutions available. People had to go outside the region to seek help.

The question is: Is the team of engineers keeping itself updated on the latest trend, the latest technology? How about the latest skills for problem solving? I think what we need to do is to understand what works and what does not work. We don’t have to design the same thing that our fathers designed 30 years ago. We need to do it better, and to do it better, we need to educate ourselves. We have come a long way, yes, but we still have more distance to cover to make the region comparable to the West, in terms of standards.

The observations you shared during your presentation – MEP elements and HVAC equipment failing as a result of poor design – are quite worrying, in terms of their impact on IEQ, particularly in the areas of thermal comfort and air quality. Would you say that they reflect the current general scenario in the region? 

I am not sure if they do reflect the whole scenario. I only know what I am exposed to, which are projects designed a long time ago that lack the required solutions and features. And if they are lacking, it becomes a problem for the hundreds of patients who move in and out of these healthcare facilities, a problem for the physicians working there, who might not understand why their patients are not getting better or are falling even more ill.

I think that owners of hospitals need to take a hard look at why we have this problem. All hospitals have a way of measuring their performance and their patients’ comfort – of measuring the patients themselves. Are they repeatedly coming or are they new patients? Owners need to take a serious look at their infrastructure. Have they been designed to meet the latest code or not? If they are, have the design specifications been executed or followed? Often, people in the construction industry go into the business of what we call ‘value engineering’, and many of them have taken to equating value engineering with cutting down the costs, no matter what. How can there be value in reducing ventilation, in removing fresh air? I think value engineering ideas must go through and be approved by designers.

You have been involved in a couple of mega healthcare projects in Saudi Arabia – one being a 4,000-bed medical city. Do you think the current codes and standards being followed by the region’s healthcare industry will be sufficient to address design, operations and maintenance issues for such large projects?

These mega projects in Saudi Arabia are in a league of their own. We have not seen a 4,000-bed project designed before. In the United States, a 1,500-bed is the fourth largest hospital in the country, but that 1,500-bed hospital grew to that size in time. It’s around a hundred years old.

These mega projects are in a totally different level. The codes apply but only to a certain point. You need to take the codes and extract from them, draft questions, go back to authorities and ask for interpretations. So I think the codes and standards do address the issues, but the question is – to what extent? It’s a critical question, because these projects are new to the whole world. The United States doesn’t have anything like a 4,000-bed facility. There are campuses that have 1,000 beds or 1,500, but they reached those numbers over time. They weren’t designed that way in the beginning.

But I think the Saudi Arabia Ministry of Health will surely do a good job in selecting the engineers and making sure that they are qualified, are updated on the latest industry standards and are prepared to address potential problems of these mega hospitals, because these projects have very different, very complex requirements. So we need engineers who understand problems that may arise during operation. Engineers need to have a vision of what may go wrong. What can go wrong shall go wrong – that’s the theory, right? Therefore, what can go wrong must be addressed from the start, instead of being buried under system after system after system. Complex systems are not always the solution – they perhaps generate more issues than they resolve. What is really important in design is its maintainability. It is crucial to the safety, health and comfort of patients.

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(The writer is the Assistant Editor of Climate Control Middle East.)