4D Models for Safety Planning of Hospital Renovations by Bert Lankheet

Working Paper #5 4D MODELS FOR SAFETY PLANNING OF HOSPITAL RENOVATIONS

Bert Lankheet & Timo Hartmann

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4D models for safety planning of hospital renovations Bachelor thesis Civil Engineering, 22th of april 2010, Enschede, Bert Lankheet

Bert Lankheet (s0150029) Bachelor Student Civil Engineering University of Twente, Enschede, The Netherlands b.g.h.lankheet@student.utwente.nl University supervisor: Timo Hartmann, Assistant Professor University of Twente, Enschede, The Netherlands T.Hartmann@ctw.utwente.nl

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Abstract

processes. Maintaining hospital operations during hospital construction projects leads to hazards, following

from interferences between construction and medical processes. Conflicts between those processes are

undesirable because medical processes are very vulnerable. Hospitals and its inhabitants suffer from these

interferences. Therefore, aligning medical & construction processes during the planning stage is very important

for hospital renovation projects. Various specialists are involved in the planning of hospital renovations. It is

important that they have insight in the project, to detect errors in the construction plan, and to devise safety

measures effectively. Compared to traditional 2D scheduling methods, 4D modeling methods help planners

and practitioners to associate time and space in the pre-construction phase. I developed a 4D visualization

method to support project teams in the planning of safety measures, and hospital and construction processes.

This paper reports the findings from a case study, it also introduces the method. In the study, the 4D models

appeared to be useful for construction specialists and medical specialists, because they allowed for a better

understanding of the construction plans and drawings. This provides first evidence that 4D models can support

in hospital construction projects.

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Keywords: 4D model, BIM, hospital construction, medical processes, construction processes,

During hospital renovation, medical processes are, oftentimes, in progress at the same time as construction

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1 Introduction

As a cause, construction processes often interfere with medical processes. These conflicts between equipment,

workers, and hazard spaces, are undesirable because medical processes are very vulnerable (Kamat &

Martinez, 2005). During construction projects hospitals and its users, suffer from construction dust, fires, and

cost & time overruns. As an example of unwanted effects from construction dust, hospital acquired infections

are a major problem during renovations because of the dust and spread of mold spores throughout the air

(Feldbauer, 2009). Researchers established construction activity as an independent risk factor for infection risks

(Weems Jr, Davis, Tablan, Kaufman, & Martone, 1987). Furthermore fire outbreak risks as a cause of advanced

hospital installations, medical gasses, and immobile persons, also make renovation projects risky. Besides this

the complexity of hospital construction, among others, leads to cost & time overruns. Therefore it is important

to involve different disciplines in the design and planning process, to create safe, feasible, and cost-effective

plans.

During hospital renovation, medical processes are, in progress at the same time as construction processes are.

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Planning of hospital renovation projects therefore requires an integrated project approach. When different

specialists are involved in the planning of the project, it is likely that the project will have a bigger chance to be

successful. Though an integrated project approach demands that all project team members understand the

construction plans. Only then, the project team members are able to take successfully part in the design and

planning process, and to give their opinions and solutions. Hence, when people understand plans, they will be

more aware of the risks, and they can think of solutions.

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There are different ways to present construction plans. Usually project planners present information with bar

charts and network diagrams. Typically construction planners used these tools together with design

documentation (2D or 3D drawings and specifications) to produce a construction schedule consisting of a set of

activities and sequential relationships. Then the construction planner mentally associates this schedule

information with the graphic representations of the building. But this â&#x20AC;&#x2DC;mental modelingâ&#x20AC;&#x2122; is limited because of

the ability to deal with project information changes and the limited memory of a planner (McKinney & Fischer,

1998). 3D drawings already give laymen, as well as engineers, a better understanding of project information.

But when presenting a construction schedule, these drawings lack a time dimension. Therefore project teams

should use 4D models, 4D models link components in 3D CAD models with activities from the construction

schedule (Fischer & Kunz, 2004). Taking this into consideration, the need for careful planning is obvious and the

application of 4D tools is likely to support the partnering process between architects, construction companies

and medical specialists (J Bartley, 2000). Therefore I developed and tested a 4D modeling method to support

project teams on hospital construction projects.

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Researchers examined the application of 4D models on hospital renovation projects (Fischer & Kunz, 2004;

Garcia, Kunz, Ekstrom, & Kiviniemi, 2004; Heesom & Mahdjoubi, 2004; Kunz, Levitt, & Fischer, 2003; Webb &

Haupt, 2003) but there are no clear findings about usage to increase patient safety. In addition to this, there is

little known about how to model in 4D, few studies describe methods to model. I developed a modeling

method that applies color coding, objects, surfaces, symbols, and text, linked to time, to represent hospital &

construction processes and safety measures. The method which I introduce, should be a step towards the

wider use of 4D models during patient safety-related decision making in hospital renovation projects. I

developed and tested the modeling method during an exploratory case study on the preliminary design phase

of a middle-sized hospital renovation project in the Netherlands.

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This paper reports the findings of this case study. The study showed that project teams on hospital renovation

projects can benefit from the use of 4D modeling. Some participants stated, that various specialists involved in

the renovation project planning, often did not understand 2D design documentation, 4D models seemed to

help practitioners to understand design documentation. This research finally leads to a method to visualize

safety measures, and hospital & construction processes.

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The paper starts with the theoretical points of departure for the research. After this theoretical background,

the paper describes the 4D modeling method for visualizing of hospital construction projects. Following this the

paper describes the case study methodology used in this research. Next to this the paper reports the findings

obtained during the introduction of the modeling method in meetings with project team specialists. Then the

paper lists the limitations of the research. In the following part of the paper I summarize the theoretical

contributions of the research. Following this the paper discusses the practical implications and contributions.

and possibilities for future research.

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2 Theoretical points of departure

infections, fires, budget overruns, and construction delays. Therefore construction, renovation, and

construction activities in health-care facilities require substantial planning and coordination to minimize the

risks both during projects, and after their completion (Sehulster, et al., 2003). The impact of construction

activities in hospitals depends firstly on the size of work and the â&#x20AC;&#x153;patient group areaâ&#x20AC;? where the work takes

place (Werkgroep Infectie Preventie, 2007). For instance the impact of construction work in the entrance hall

of a hospital is less severe than the impact of construction work in a surgical department. Furthermore during a

renovation, a hospital often remains in operation, because closure is very expensive. Therefore project teams

have to consider carefully, which impacts construction activities have on hospital operations. Analyzing the

most important incidents occurring during hospital construction is a starting point, for the development of

visualization tools for project teams.

Construction in hospitals causes risks and problems, the most important resulting from construction are:

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First construction activities can indirectly cause hospital acquired infections, because construction dust and soil

almost always contains pathogenic spores. The spreading of construction dust may occur via shoes, clothes,

gravity, and air flows in the building (J Bartley & Bjerke, 2001; Werkgroep Infectie Preventie, 2007). To prevent

spreading of harmful dust, project teams have to coordinate: patient & medical staff routing, construction

worker & material routing (Wischer & Riethmuller, 2008). Thereby contractors have to isolate the construction

site from the rest of the hospital. As a consequence construction workers and material are not allowed in areas

where patients, medical staff, and medical material are. But it is often not possible to fully isolate the

construction site from the rest of the hospital. To solve this problem, project teams can decide to transfer

patients to other hospitals or departments. But transferring is often not possible due to a lack of capacity.

Therefore authorities and researchers established guidelines and protocols with measures to reduce the

amount/and spreading of dust during hospital construction. Practitioners may choose to isolate the

construction site with dust barriers, dust barriers keep dust out of patient areas. Thereby it is necessary to plan

routes for patients, material, medical staff, and construction workers.

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Next to the problem of hospital infections, construction activities in hospitals also increase the risk for the

outbreak of fires. Hospitals are full of dangerous equipment. For instance anesthesia equipment contains

medical gasses as oxygen, carbon dioxide, medical air and nitrous (Inspectie voor de Gezondheidszorg, 2008).

Hospitals have to control the storage and transport of these gasses to prevent the outbreak fires. Inadequate

use and storage can lead to disasters (Onderzoeksraad voor de Veiligheid, 2008). To reduce the harmful effects

of the outbreak of fires, hospitals must have an adequate evacuation plan. Fire evacuation plans for hospitals

differ from plans for other buildings and institutions, because hospital patients are often immobile. The

evacuation plans of hospitals consist of emergency escape routes and protocols for the treatment of patients.

Project teams have to take fire safety into account already, during the start of the facility design.

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Having discussed the tangible problems, a hospital construction project also faces financial and schedule

challenges. Renovations of hospitals are often more expensive and last longer than planned. Thereby

renovations are oftentimes even more expensive, than the construction of a new hospital (Wagenaar, 2006).

Cost and time overruns have several underlying causes, for instance incidents and time-space conflicts

between different contractors can cause construction delays.

When renovating a hospital, contractors have to take various safety measures. These safety measures costs

money and time. The underestimation of these measures and overestimation of the conditions of the existing

building, lead to budget overruns in the execution.

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Thus it is not only important to maintain patient safety, but also to reduce cost overruns and construction

delays. Therefore it is recommended to keep the previous risks in mind during all phases of the construction

process. Hospitals intend to reduce risks by establishing regulations and measures. Project participants should

comply to these regulations and measures when creating and executing plans, but oftentimes practitioners do

not do this, due to errors in mental modeling and misunderstanding of design documentation. These errors

occur because hospital construction demands a variety of impacts and measures. As a result practitioners face

problems during the planning of renovations, because they have to associate various construction sequences

and spatial features of the construction site (Barlow & Kรถberle-Gaiser, 2008). Next to this the implementation

of some measures may have a negative impact on other measures and construction activities. For instance

placing dust barriers has impact on the evacuation plan; dust barriers isolate areas, while planners must

maintain fire safety escape routes. Therefore practitioners require a tool that gives insight in hospital &

construction processes, and safety measures.

Table 1 provides a summary of topics discussed in project team meetings of hospital renovation projects.

Hospitals must approve plans of the architects and other consultants, before the hospital auctions the project.

It is important to know the place of doors, because together with dust barriers they play a key role in the

separation of clean and dirty areas. Hospitals also use air pressure differences to keep dirty air away from

patients. It is important to maintain these air pressure differences during construction, therefore construction

specialist must have insight in the pressure level of rooms.

Preventing infections planners also design routes for medical staff, material, construction workers, and

construction material etc.. Keeping dirty people and clean people separated, limits the risk for infections.

Thereby planners also design routes for evacuation of a department, in order to reduce the harmful effects of a

fire outbreak.

Maintaining hospital operations is desirable because it cuts the costs of the renovation project. The more

rooms are in operation during construction, the less the costs of construction are. But maintaining operations

does cause additional safety risks.

Table 1 Subject project team meetings (Lankheet, 2009)

Subject Place of doors Isolation of construction site

Air pressure level

Working times of medical staff and construction workers

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Requirement Separate ‘clean’ areas from ‘dirty’ areas. A dust barrier must isolate the construction process from the medical processes The high air pressure of clean areas must be guaranteed.

Participant responsible/involved Architects, microbiologists

Representation in meetings Traditional symbols of doors on 2D floor plans.

Architects, microbiologist, installation advisor, medical staff

2D drawings with lay-out of walls in different phases in the construction process

Installation advisor, microbiologist, architects

Operating rooms must be operational as long as possible

Medical staff, housing advisor, contractor

Pressure levels are specified for each room, this is done with text, and the place of installations is on the 2D drawings. The construction project duration is not clear on the 2D drawings, this is because no contractor is involved yet, and it is difficult to estimate duration of construction activities. The routing of patients, staff and construction workers is not visualized in 2D

Routing of patients, staff & ‘Clean’ and ‘dirty’ people must Microbiologist, medical staff, architects, contractor construction workers be separated, (during construction, and evacuation) Explanation: Clean means sterile, if a person comes into the surgical department he is sterile. But operated patients and construction workers are not clean but dirty. This means everyone and everything that not increases the risk for infection, is called dirty.

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2.1 Current planning process

expertise are involved in each phase of the planning process. Analyzing this process, is necessary to develop

new visualization methods, therefore the steps of the planning process are explained in further detail.

Hospitals frequently work with consultants during the planning phase, when generating plans for new facilities.

These consultants are architectural and construction companies (J Bartley, 2000). Architects begin with a

sketch, this is based on first needs and ideas of the client. After the architects present 2D and 3D drawings of

the lay-out to the client, they get comments, and start the next phase of the design process. In the next phase

of the process, the architectural designers generate the 2D floor plans with a higher level of detail, and they

also generate 2D or 3D models of construction details as window frames, stair constructions etc.. The project

team then generates several basic alternatives for the sequence of construction activities. Eventually they

come up with multiple alternative schedules for the reconstruction of the facility. The architectural designers

present these alternatives with multiple 2D drawings for each alternative schedule. But this 2D documentation

gives no information about the detailed sequence of construction activities, the drawings represent only a

snapshot of the construction (Koo & Fischer, 2000). The drawings are a summary of several construction

activities. It is also almost impossible to provide information about each detailed step in the construction

process with 2D drawings. Because the creation of such an amount of 2D drawings is a time consuming effort,

and the use of such an amount of drawings during meetings is dysfunctional.

These detailed 2D schedules are the result of collaboration between architects, cost estimation specialists,

legal specialists, and the client (Millsap, 2007). As a result of this the hospital is responsible for the safety

during construction. Therefore hospitals have medical, financial, and construction expertise at their

construction offices. During the planning of renovation projects, diverse project teams plan site access, site

logistics, safety measures, and evacuation plans (Finchley Memorial Hospital, 2009). All specialists have focus

on particular aspects of the construction plan. For instance, the installation specialist is responsible for the

coordination of the work on Mechanical Electrical & Plumbing (MEP), and microbiologists are responsible for

the routing of staff, patients and material. As a result the various specialists are interested in different pieces of

information.

The planning of hospital construction projects involves various phases. Practitioners with different fields of

Having analyzed the planning process, it is clear what problems planners face during the planning of hospital &

construction processes and the devising of safety measures. Analyzing these clarifies what the requirements for

4D tools are.

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2.2 4D modeling

temporal dimension to 3D CAD models, this are 4D models. Figure 1 gives a schematic representation of the 4D

modeling process. 4D models integrate the logical, temporal and spatial aspects of construction planning

information, thereby reducing the need for individual conceptualizations of the construction schedule (Koo &

Fischer, 2000). A 4D model results from the linking of 3D graphic images to the fourth dimension of time (Koo &

Fischer, 2000). The time dimension is the construction schedule. 4D construction animations show the virtual

construction and/or demolishing of a structure.

Researchers developed computerized methods to represent construction plans graphically, by adding the

2D drawings

Schedule data

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generate 3D model

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3D CAD objects

Tasks Linking 3D objects to schedule

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4D visualization

Figure 1 schematic representation 4D modeling process

In recent years more and more construction practitioners used three-dimensional/four-dimensional (3D/4D)

models to support management tasks (Hartmann, Gao, & Fischer, 2008). Researchers describe various

applications of 4D models, for instance: site management (Akinci, Fischer, & Kunz, 2002; Chau, Anson, & Zhang,

2004; Coles & Reinschmidt, 1994), multi-stakeholder input (Eastman, Teicholz, Sacks, & Liston, 2008; Fischer &

Kunz, 2004), communication of the construction schedule (Eastman, et al., 2008; Koo & Fischer, 2000;

McKinney & Fischer, 1998), evaluating different schedules (Chau, Anson, & Zhang, 2005; McKinney & Fischer,

1998), and tracking construction progress (Ma, Shen, & Zhang, 2005; Webb & Haupt, 2003).

Based on these applications, researchers established advantages of 4D models over traditional methods. A a

first advantage 4D models are effective in evaluating the executability of a construction schedule (Koo &

Fischer, 2000). Next to this 4D models allow for identification of construction problems prior to construction,

(McKinney, Kim, Fischer, & Howard, 1996). 4D models are also beneficial in communication with a diverse team

of project participants, because 4D models are easier to understand than traditional planning representations

(Fischer & Kunz, 2004). And therefore it is easier for project teams to use 4D modeling as input information for

the construction planning, as an example Fischer & Kunz (2004) describe a case where 4D modeling supported

the decision making for processes outside the hospital, during construction.

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Although researchers conducted case studies on various possible areas of application for 4D models, there is

little research done on the 4D modeling of hospital processes. Researchers studied the use of 4D modeling on

hospital construction cases and other researchers on construction worker safety (Benjaoran & Bhokha, 2009;

Chantawit, Hadikusumo, Charoenngam, & Rowlinson, 2005), but researchers did not focus on patient safety

related information. Despite North et al. (2004) already mentioned the need for virtual healthcare modeling.

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The theory supposes that there is a need for 4D modeling for safety at hospital construction projects.

Determining the required insight in hospital & construction processes and safety measures, is a step towards

the development of a tailor made 4D modeling method.

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2.3 Required insight in hospital and construction processes

occurring during construction. Applying hospital construction safety guidelines on this documentation,

practitioners have an indication of measures to take on a particular project. But practitioners need insight in

the impact of measures on the hospital & construction processes. For instance if the construction site must be

isolated with dust walls, then practitioners need to know what consequences this has for the routing of

patients. When knowing this, project teams can generate alternatives for the routing of patients.

Besides this, practitioners need to have insight in the specific features of rooms in, or adjacent to, the

renovated area. For instance air pressure levels are important during the reconstruction of surgical

departments, clean rooms must have a higher air pressure level than less clean rooms. This is done to keep less

2D drawings and safety guidelines of the reconstructed area give first information about possible problems

clean air outside clean rooms. Visualization of these pressure levels, gives practitioners the possibility to plan

suitable patient routes and sequences of construction.

The temporal dimension in visualizations gives practitioners insight in the timing of measures, and problems

resulting from this. Associating time and space with 4D models is easier than with traditional methods

(McKinney & Fischer, 1998). Transitions between phases can cause problems, as an example contractors must

thoroughly clean reconstructed areas, before they are ready for use. If this area is a corridor, it can delay the

project as the corridor must be used for routing of patients and medical staff. In this case it might be sensible

to first create a new, temporal, access before reconstructing the old. The temporal dimension also allows

practitioners to evaluate multiple project schedules. Practitioners get insight in the duration of various

alternative schedules; for instance renovating a department at once takes less time than renovating a

department in multiple phases while a part remains in operation.

Furthermore the visualization of information allows planners to detect safety hazard situations prior to

construction. Detecting these hazards, gives practitioners the possibility to devise solutions. The visualization

allows practitioners to virtually implement the solutions. This gives them insight in the consequences resulting

from implementation of possible solutions.

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2.4 Application of 4D models

thereby the decision making of practitioners. I examined the application of a 4D modeling method on hospital

construction projects. The 4D modeling method I developed, aims to visualize hospital & construction

processes and safety measures. The 4D models created with this method give practitioners insight in hospital &

construction processes, and safety measures during hospital renovation projects. The 4D models consist of

various elements: spatial, textual, and temporal. Figure 2 gives a schematic representation of the process

diagram of the 4D modeling method. Information visualized with this method, results from a combination of

information, namely building design documentation, hospital safety guidelines, and information about ongoing

hospital processes. The method derives safety measures from existing public health agency documents

(J Bartley, 2000; J. Bartley, 2006; Centers for Disease Control & Prevention Healthcare Infection Control

Practices Advisory Committee, 2003; Werkgroep Infectie Preventie, 2007) and protocols of the hospital itself.

Concluding from the discussed theory, 4D models are an appropriate tool to support the information and

Hospital process follow from analysis of the department involved in the renovation work. For instance surgical

departments have other processes running than a pediatric ward.

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Figure 2 Process diagram of 4D modeling method for hospital renovations Building design data

Safety guidelines data

Hospital process data

Client demands, requirements

7 2D construction sequence drawings

First indication required measures

Generation 3D models

Generating tasks and sequences

Basic 3D building model

Selection appropriate visualization method for each measure and process

Spatial method:. Addition 3D objects

Construction schedule

Textual method: Addition text & symbols

Spatial method: Addition surfaces

Temporal method: Creating tasks and tasktypes and add colors to these

3D models of measures & processes

Appending 3D models with measures and processes to basic 3D building models

3D model of building with visualized measures & processes

Creation selection sets

Selection sets Link tasks to task types and selection

sets

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4D models are amongst other things created with 3D models. To create basic 3D models, the method uses

existing 2D and 3D design documentation. The basis of the 4D model consists of two 3D models of the building,

one model of the building before the renovation, and one model of the building after the renovation. 2D

construction sequence drawings provide a starting point for the scheduling of the activities. These 2D models

summarize multiple activities of the hospital renovation project. Reason for using 2D is, that sketching in 2D is

less time-consuming than directly creating 4D models. Therefore 2D models allow for a quick generation of

multiple basic scheduling alternatives. These scheduling alternatives provide the basis for a list of sequential

tasks.

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To add a temporal dimension to the model, the method uses colors. Previous researchers already proved the

appropriateness of color coding for 4D visualization (Chau, et al., 2005; McKinney, Kunz, & Fischer, 1998; Wang,

Zhang, Chau, & Anson, 2004). To apply color codes in the 4D model, the method uses created selection sets out

of the 3D models, and then adds task types to these selection sets (See Figure 7 for an example). A task type

represents a categorized task group, for instance the task type demolish. Selection sets added with this task

type then have this color during the activity. The demolished parts are invisible at the end, through setting the

end appearance to â&#x20AC;&#x153;hideâ&#x20AC;?. Linking all task types and selection sets, results in a 4D model. When a task is active,

the linked 3D objects gets colored, appears, or disappears. Task types and tasks represent the temporal

dimension. Integrating these temporal and the spatial dimension, which the objects and the building are,

makes the model a 4D model. Inserting a legend helps people to understand the colors of the model.

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To show dust barriers, the method applies a spatial method, by adding models with 3D objects (Figure 3) to the

3D model of the building. 3D models with these objects are merged with the existing 4D model. This

visualization gives practitioners insight in barriers, obstacles and risks during construction. Linking the added 3D

objects to a task-type, allows for 4D visualization. Practitioners may use this information to detect accessibility

problems, and impacts on adjacent areas. Using the method I saved the 3D objects in separate models,

because saving in different model files supports the quick visualization of project changes.

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1 2 3 4 5 6 Figure 3 Snapshot of a 4D visualization of a schedule alternative with 3D dust 7 Barriers (red) surrounding a reconstructed area, new constructed elements are transparently green. 8

To visualize zone conditions as air pressure, the method applies surfaces, a spatial method. Creating these

surfaces the method also uses 3D modeling software. Visualizing for instance air pressure zones I used floor

surfaces. The surfaces are 3D objects created with 3D modeling software. I choose to give each room a

separate floor section, because this supports the creation of selection sets. Applying color coding on the

surfaces supports to identify them, see Figure 4. These surfaces in 4D visualizations give practitioners insight in

the conditions in areas, and functions of it. In case of visualizing air pressure zones; this gives installation

specialists an indication of the feasibility of schedule alternatives. Installation specialists must isolate the HVAC

system of the construction site from the HVAC system of the rest of the hospital, to keep dust away from

patients.

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Figure 4 Snapshot of a 4D visualization of a schedule, the blue floor surfaces visualizes areas with air pressure level B

To visualize routes for people, material, and evacuation of these, the method applies textual annotations and

symbols. Chantawit et al. (2005) also used textual annotations for safety planning of activities. Addition of text

and symbols happened through creation of another 3D model. The method uses a 2D floor plan of the building

model within a new 3D model, to put text and symbols on the right place. Merging the model with text and

symbols with the other 3D models, allows to model in 4D, see Figure 6.

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Figure 5 Snapshot of 4D visualization, in the upper left corner a legend for the used colors

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Figure 6 Snapshot of 4D visualization, text an arrows visualize evacuation routes and routing of sterile and non-sterile material

4D models created with the above explained method, theoretically give practitioners insight in hospital &

construction processes and safety measures. The method addresses to the need for new visualization tools to

support the planning of hospital renovation projects. But until here it is only theory described, therefore the

4D models are tested in practice. The case study focuses on testing, and validating the 4D modeling method.

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Figure 7 Task type interface (Timo Hartmann, 2009)

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3 Research method

various advantages over traditional design documentation. The main goal of the study is to explore the

applicability of 4D models, for hospital renovation projects, and the described 4D modeling method in

particular.

It is plausible that 4D models are useful for the planning of hospital renovation projects, because they have

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Examining the usefulness of the 4D modeling method, I used ethnographic action research methods (T

Hartmann, Fischer, & Haymaker, 2009) and exploratory case study methods(Yin, 2002). Case study methods

are useful for the goal pursued, because then the resultant theory is likely to be empirically valid (Eisenhardt,

1989).

I conducted Ethnographic-action research using qualitative methods as interviews and observations.

Researchers usually describe the action research process as iterative cycles of observation of practitioners,

identification of problems, development of technical solutions, and implementation of the developed solutions

(T Hartmann, et al., 2009). Observing working routines and meetings within a project, allows to develop a

useful method for practitioners. Figure 8 outlines the research and validation process. Using this cyclic

approach I aim continual improvement of the modeling method. This cyclic approach is based on the

ethnographic-action research cycle of Hartmann et al. (2009). Research cycles are typical for action based

researches. The case study should be a first step in the validation of a 4D modeling method for hospital

construction projects. First I generated a 4D model based on 3D models of the company, and available safety

guidelines. Introducing the model to specialists, and discussing it with the specialists resulted in adjustments

and thus validation of the model.

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Theory

Case

Theoretical points of departure; Theoretical 4D modeling method

4D model

10 11 12 Case specific information Interviews, documents

Data analysis

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Observations and information obtained during introduction of 4D movie in meetings

Generation of 4D model

4D movie

Figure 8 Cyclic research and validation process for 4D modeling method method

Using these exploratory case study methods I conducted the case study at an architectural design firm in the

Netherlands. Being one of the biggest architectural firms in the Netherlands, the firm gained experience in

delivering a variety of projects, including hospital renovations. The firm was working on a plan for the

renovation of a surgical department of a middle sized hospital (â&#x201A;Ź12-17 million) in the Netherlands, see Figure 9.

Realization of the project is scheduled to start in the summer of 2010. The renovation was necessary, because

equipment and architectural features were outdated and did not longer meet todayâ&#x20AC;&#x2122;s requirements.

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Figure 9 The surgical department

This case is deliberately selected, and thus not random (Yin, 2002). Multiple characteristics make this case a

suitable for the aim of the research. First reason for choosing this project is that surgical sites are among the

most vulnerable areas of a hospital. Operated patients are very susceptible for infections, because they often

have open wounds, patients also have a poorer functioning immune system. Therefore the environment,

medical staff, and material must be absolutely sterile. As a result of this, project teams faced various problems

during the planning of previous surgical department renovations (AORN, 2008; J Bartley, 2007; J Bartley &

Bjerke, 2001; Burril, 2007; Madrid & Hernandez, 1999; Mee Cheng & Streifel, 2001; Patterson, 1987; Streifel &

Hendrickson, 2002).

The second reason for choosing this case, is that hospital managers wanted the department to remain in

operation during the renovation. This increases the likelihood of incidents, as hospital processes may interfere

with construction processes. Hence the project team must devise strict safety measures.

As a third reason, surgical departments are full of dangerous equipment, this causes risks for the outbreak of

fires. Project participants dealing with this risks, must have insight in the consequences of fire safety measures

in relation to the other processes in the surgical department.

Furthermore many Dutch hospitals plan to renovate their surgical departments in the coming years, because of

higher requirements following from new regulations (College Bouw ziekenhuisvoorzieningen, 2004). This makes

the study a sound and representative sample for future hospital-, and especially surgical site renovation

projects.

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Task of the firm was to deliver a feasible plan, feasible meant: executable, within the available budget, and

fulfilling the functional requirements of the client. During the planning phase, the firm collaborated with

advisors of the construction office of the hospital, which was the client in this project. The architectural design

company was concerned with the preparation of a first plan for construction sequences. The sequences of the

renovation activities have a significant impact at the safety, the duration, and the direct & indirect costs of the

project. The firm was involved in this, in order to examine the feasibility of a new constructed department,

and/or full closure of the department during construction operations, instead of maintaining operations during

construction. As a consequence the company was not familiar with their new (extra) role (College bouw

zorginstellingen, 2006) in the construction process.

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The selection of processes and measures to visualize in 4D models, occurred by choosing in a way that each

modeling element is represented in the 4D models. The subjects relate to Table 1. The selected subjects are

summarized in Table 2. Selection of safety measures occurred in collaboration with medical and construction

specialists, who applied existing safety guidelines.

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Practitioners of the architectural design firm used the model, to support the discussion of scheduling

alternatives during an internal project team meeting. The internal project team consisted of two architects, an

two architectural designers and a project manager. Additionally participants described in Table 3 discussed the

4D models during semi-structured interviews (Wengraf, 2001). The meetings support the validation of the 4D

model. The participants of these meetings represent a number of specialisms involved in hospital renovation

planning. Selection of specialists occurred by availability. The meetings allowed to obtain information about

the usefulness of the 4D models in giving insight in hospital & construction processes, and safety measures.

During these meetings, the experts discussed traditional design documentation and 4D models. At the end of

the meetings, I introduced 4D models to the participants. Presentation of the models occurred on a laptop,

except the presentation for contractors, this happened with a beamer. Table 3 provides a summary of the

specialists, that participated in the research.

Table 2 subjects, traditional presentation, 4D presentation

Represented plan requirements in 2D drawings Separate ‘clean’ areas from ‘dirty’ areas.

How represented in traditional meetings Traditional symbols of doors on 2D floor plans.

A dust barrier must isolate the construction process from the medical processes

2D drawings with lay-out of walls in different phases in the construction process, the walls are colored,

The high air pressure of clean areas must be maintained.

‘Clean’ and ‘dirty’ people must be separated, and an evacuation plan must be available Construction sequences Maintaining hospital operations

5 6

Also the border of the construction site is colored Pressure levels are specified for each room, this is done with text, and the place of installations is on the 2D drawings. The routing of patients, staff and construction workers is not visualized in 2D Multiple 2D drawings Construction site is surrounded with a line

Representation in 3D/4D Colored cubic objects over the areas Colored floor surfaces Colored wall without doors The border of the construction site is also visualized with colored walls

Pressure levels are represented with colored surfaces, operating rooms are represented with colored cubes and/or colored walls 3D text and arrows.

Appearing and disappearing objects, changing colors of objects Rooms in use for medical operations have a surface

Table 3 Participants of meetings, and their specific responsibility

Participant

Responsible for:

Number of meetings with participant

Architect Architectural designer Project manager

Planning & design Detailed design of room lay-out Ensure that customer demands and wishes are translated into construction plans, continual review of the feasibility of the plan Patient safety Safe, time & cost effective execution of the construction plans Communication with clients of the Architectural design firm

2 2 2

Infection control professional (ICP) Contractor

Communications advisor

1 1

7 8

1 2

4 Findings

the internal project team used a 4D model in an internal project team meeting. In the beginning of the

meeting, the project team used a schedule consisting of several 2D drawings of phases of the construction.

Using the 4D model the participants began asking questions about the transition between the phases of the

construction, and the accessibility of the construction site.

To support the discussion about feasibility of scheduling alternatives of the surgical department renovation,

Figure 10 snapshots of phases visualized with 4D movie, the last snapshot shows the construction activities in the entrance corridor

7 8

To maintain hospital operations during the construction project, medical staff and patients must have access to

the construction site. The team planned to construct an internal wall next to a cavity wall, in the end of the

renovation project. This operation should take place in the main entrance corridor of the surgical department.

The 4D model helped to make the participants of the meeting aware of the fact that this may lead to

accessibility problems during construction.

Furthermore, when one phase is finished, i.e. when construction workers and installers finished their work in

one part of the surgical department, they should begin with the renovation of the next part of the surgical

department. With 2D documentation the project team did not detect problems that may arise during this

transitions. Using the 4D models the participants start asking if it was very optimistic to assume this. Then it

appeared that operating rooms need equipment validation and conditional validation when constructed, this

validation took about three weeks. Knowing this, the project team asked the client if it should be sensible to

close the whole surgical department, as the validation period could lead to delays.

8 9

Figure 11 2D Drawing of construction phase

Another issue forgotten, or assumed not to lead to problems, is the impact of placing dust walls. 2D drawings

only represented summaries of construction phases, for instance Figure 11. Using the 4D model (see Figure 12)

the project team discovered that placing of the dust barrier itself may cause problems, as it is a construction

operation and thus produces dust. As a result the project team decided to reserve a period for the placing of

the barriers. Next to the placing of dust walls, workers then also clean the department during this period.

1 2

Figure 12 snapshot of 4D model of construction phase

3 4

Next to the internal project team using the model, they and other specialists mentioned in Table 3 gave

feedback on the model after looking at it during interviews. The findings follow from discussions during these

interviews. Concluding that some topics recurred in every discussion, these topics are categorized and

summarized in Table 4. Validation findings are categorized following these topics. This should help in improving

the 4D modeling method in general.

Table 4 Topics discussed in validation meetings

Topic Comparison of 2D based methods with 4D modeling Required information Level of detail Possible areas of application Feedback visualization methods 4D models General feedback on 4D models

10 11

Starting with comparisons between traditional methods and 4D, the architect made the first comparisons. He

said that during a project team meeting about the surgical site renovation, he experienced problems

presenting schedule alternatives. ‘2D drawings provide a summary of the activities, but presentation becomes

chaotic due to multiple alternatives, and thus multiple sets of 2D drawings’. Describing a meeting with project

team members of the hospital, he said ‘First specialists did not understand these, and then specialists began to

give comments’, this resulted in a chaos, because all specialists want to give their opinion, and 2D drawings are

not suited for this applications’. According to the project manager; the 4D models may support in these

meetings, ‘4D models may clarify the plans, certainly better than 2D drawings’ because they 4D models insight

in the spatial and temporal dimension of the plan. The project manager also mentioned the advantage of 4D

models, in understanding the lay-out of installations; ‘where 2D drawings have a reasonable picture of

buildings, 2D drawings of installations are very hard to understand for laymen’. The medical specialist said, ’2D

drawings are rather hard to understand for non-architecturals, 3D models already allow for a better

understanding, and 4D models certainly do’. The contractor suggested that 2D drawings did not give as much

insight in planning errors as 4D models do , ‘because 4D models are a combination of spatial and temporal

information’.

Discussing the required information presented with the 4D model, the architects asked, ‘can you show

architectural details with the model?, like the connection of floors to walls’. In relation to this the architectural

said that ‘linking detailed 2D construction details to the 4D models might be a solution’. On the other hand the

medical specialist wanted ‘to see how beds are placed in the rooms of the surgical department, this often leads

to problems in newly built hospitals, because beds do not fit in the rooms or cannot turn in corridors’. She also

stated ‘for infection control planning, it is important to visualize people and material routing’. The contractor

suggested ‘are you able to show more detailed sequences of activities?, doing this we are able to detect errors

in the construction process’. Following this he stated ‘we want the 4D model to present the detailed

construction activities for, for instance building a wall’. The contractor stated that ‘using the model is only

worthwhile if it contains detailed visualizations of construction activities’. This leads to the next topic discussed

in the meetings; the level of detail.

The communications advisor found that ‘no matter what information you want to present, it is always

important that all information presented with the model is clear, a high level of detail results in a surplus of

information, and thus ambiguities’. The architect said ‘the required level of detail depends on the participant

using the model, ‘I want to see architectural details, but this is not relevant for medical practitioners’.

According to the project manager, ‘the level of detail should change during the planning process, where in the

beginning there are many uncertainties, then it does not make sense to show details, this only raises a lot of

questions’. The medical specialist considered, that people without a technical background, ‘should particularly

understand the visualization, and therefore it is necessary to show for instance doors, and windows’. As

discussed earlier contractors said they require ‘a high level of detail ‘

Reviewing the practical use of the 4D models, all participants came up with possible applications on hospital

construction projects. The architect was especially interested in use of 4D models for external communication

and input for project team meetings, ‘we want to use 4D in the future to clarify plans to clients, to get them

involved in the planning process’. The architect also already used the model to get insight in different

scheduling alternatives. The ICP said that 4D models are ‘an opportunity to really involve medical specialists in

the planning process’, while they normally not really got involved. Also mentioning the possibility to use the

model to inform construction workers, ‘in order to make them more aware of the risks’.

8 9

The project manager stated that 4D models are useful to avoid ambiguities in project team meetings, ‘we

experienced problems in previous project team meetings with medical specialists, this is a meeting where 4D

models could serve as a supporting tool’. Contractors found 4D models an opportunity to save on failure costs,

‘errors in planning and design lead to failure costs that form a large part of construction costs’. Besides this 4D

models are useful ‘in the communication with clients, when clients and hospital users know what the plans are

they will be more aware of the duration and risks.’

As a next topic all specialists gave feedback on the used visualization methods. The architect said that ‘color

coding is an effective way of visualizing the temporal dimension of project plans, it is also useful to put

emphasis on a particular point of the plan’. However the communications advisor criticized the color coding

because ‘it contained too much different colors and text’. The architect & project manager also said this during

the second meeting. The architect found that ‘it is important to find balance between the amount of

information showed in the model, and the clarity of the model’. According to textual methods, the ICP stated

‘such method is useful when working with routing of various things, like construction workers, medical staff

and patients’ because use of for instance arrows with multiple colors, confuses viewers. The duration and

playing speed of the 4D visualization also lead to discussion. Both the communications advisor and architect

found that the speed of the animation should be adapted to the presentation. ‘When we want to use the 4D

model, it must be integrated in the oral presentation of the architect, therefore it should be slow enough to do

this’.

In general all participants reacted very positive to the development of new visualization methods, such as 4D

models, for hospital renovation projects. The contractor considered, ‘new visualization methods are can help

cutting total project costs’. The architect and project manager found that they want to use the model as ‘input

in project team meetings’, but therefore it is necessary to visualize installations like the HVAC system, as

‘installations play an important role in hospital renovations’. ‘4D models may help to involve medical specialists

in the planning of hospital construction projects’ the ICP said.

5 6

5 Limitations / Future research

complete, there are some marginal notes. Future research may help to fill these gaps, there is also work

resulting from the case study.

Although the study is a representative sample for hospital renovations, and 4D models generated are

9 10

As a first note, I conducted the case study during the preliminary design, this is very early in the construction

process. The validation of the method was not complete, the introduced 4D modeling method needs

development. Stakeholders can use 4D models for communication, schedule evaluation, and even in the design

process. Until now only few participants validated the model, it is important to gain more knowledge about the

execution of hospital construction projects to develop the method. Therefore validating and testing the model

in collaboration with contractors will help to detail the different 4D models further, thereby it is also sensible to

integrate installations in the models. Researchers also have to examine the integration of 4D modeling

methods in existing working routines and planning processes (Hartmann, et al., 2008), to actually implement

4D models in practice.

19 20

Secondly it is also important to know that the architectural design firm just started implementing 3D modeling,

therefore 3D models already appeared to be a major improvement compared with the traditional method, 2D

drawing. However the company is convinced that 4D modeling offers many possibilities in future projects. But

practitioners experienced that integrating installations in the models is a must.

24 25

At this moment the 4D models are not suitable for meetings with installation specialists, integrating

installations fell beyond the scope of the study. Nevertheless installations are a very important part of hospital

construction project, medical equipment is very sophisticated, and determines an important part of the plans

and thus of the direct costs. Future research and work, will leads to solutions for this. It is important that

contractors, for example installation advisors must also work with a 3D modeling method. This in order to use

their drawings for 4D modeling of Mechanical Electric & Plumbing (MEP) system. MEP coordination has already

proven to be effective (Khanzode, Hartmann, Fischer, Reed, & Mack, 2006; Staub-French & Khanzode, 2007) .

4 5

Next to this 4D modeling has some general problems, as software compatibility. The 3D modeling software

used during the case study is not fully compatible with the 4D modeling software, although I generated the 3D

models with software of the same software publisher. Compatibility problems manifest during the 4D

modeling. The 3D objects are connected to each other in the 3D model. In order to assign tasks to these apart

objects, it is necessary to unlink the objects. Therefore generating 3D models takes a lot of time, because the

software is not optimized. As a cause I was not able to produce many models. Future development of the

software will solve this problem, it is even possible that practitioners may generate models themselves, instead

of letting trained modelers do this.

13 14

As another area of future work, practitioners themselves may be able to generate 4D models of hospital &

construction processes and measures. Doing this practitioners can focus attention of the part of the model that

is important for them. But for this, practitioners need a manual with 3D & 4D modeling guidelines. This paper

provides in a basic explanation of the modeling methods, but widespread use requires clear standards and

manuals that explain the method step by step.

19 20

6 Theoretical contributions

traditional methods as 2D design documentation, bar charts, and network analysis. Thereby the research

explored the applicability of 4D modeling in supporting safety planning of hospital renovation projects. So far

most research done on 4D modeling did not focus on patient safety related issues. Previous researchers

focused especially on construction planning of hospital construction projects (Fischer & Kunz, 2004; Garcia, et

al., 2004; Heesom & Mahdjoubi, 2004; Kunz, et al., 2003; Webb & Haupt, 2003) and construction worker safety

(Benjaoran & Bhokha, 2009; Chantawit, et al., 2005) rather then in-hospital construction planning.

The study contributed to several aspects of the theory about 4D modeling. 4D models likely do this better than

Previous applications of 4D modeling on hospital construction projects, such as Fischer & Kunz (2004) and

Heesom & Mahdjoubi (2004) , did not describe a concrete method to involve practitioners in the planning of

activities and safety measures. Thereby Hartmann et al. (2008) suggested that researchers need to examine

how practitioners can use 4D models easily. A limited number of papers show simple and useful

implementations of 4D modeling on projects, and however the method is not implemented, this research is a

step towards it. The research provides a 4D modeling method for visualization of hospital & construction

processes and safety measures in hospital renovation projects. Introducing spatial, textual, and temporal

methods to visualize hospital & construction processes and safety measures, the method aims to give

practitioners insight in problems and hazards arising during hospital renovation projects. This combination of

previously examined methods (Chantawit, et al., 2005; McKinney & Fischer, 1998) enables practitioners to

choose an appropriate way of visualizing for several processes and measures.

12 13

Results of the study also showed that the required information in a 4D visualization differs by the specialist

using the model, for instance architects are interested in the architectural features, where medical

practitioners want to be informed about the routing of patients. Therefore project teams need several models

to adopt 4D modeling successfully, and thus achieve integral use of 4D models.

17 18

As a next contribution this research is one of the first studies to give construction related practitioners insight

in the risks and safety problems arising during hospital construction. The research views construction activities

as hazardous for both medical staff, patients and construction workers. Previous construction related

researches merely saw hospital operations as normal constraints (Fischer & Kunz, 2004; Garcia, et al., 2004;

McKinney, et al., 1996). This implicates that researchers are not all aware of the health risks resulting from

construction activities in hospitals.

24 25

In summary the research contributed to theory, by introducing a 4D modeling method for visualization of

hospital & construction processes, and safety measures. The 4D models created give practitioners insight in

the effects of construction activities on hospital operations, and the effects of safety measures. 4D models are

likely to be more effective than traditional methods such as 2D drawings.

29 28

1 2

7 Conclusion

planning hospital renovations. The 4D modeling method is developed on the preliminary design phase of a

hospital renovation project. Multiple elements of visualization of processes and measures, showed to have

great potential in planning hospital construction projects. However further research is needed to come to the

actual implementation of 4D modeling in the planning process.

By visualizing multiple aspects of hospital construction, the 4D modeling method supports practitioners in

7 8

Besides contributing to theory the study also contributed to practice. With the 4D modeling method

practitioners are able to effectively devise safety measures. Visualizing these measures, practitioners have

insight in the consequences of safety measures on other measures and processes.

11 12

The 4D models visualizing hospital & construction processes, and safety measures, are relatively easy to

generate, therefore practitioners might create these models themselves. Another feature that contributes to

the usability, is the fact that all measures and processes are saved in different models, thus implementing

changes in the model is relatively easy. While practitioners have better insight in project plans, and can

implement changes quickly, they will detect safety hazards, and errors that lead to cost and time overruns.

17 18

Next to the primarily discussed application as input for decision making meetings, practitioners can use 4D

visualizations to communicate plans to users and staff before the execution phase of the project. Users being

aware of hazards and risks, will likely handle accordingly safe. Another fact that argues for the use of the

method is that practitioners suggested they are willing to use the method in future projects. This is supported

by the fact that the architect explained about problems he perceived during project team meetings.

23 24

Another opportunity for the implementation of 4D modeling is a change in the Dutch regulations for hospital

renovations. The hospital approached this particular renovation project at a relatively new way. Due to changes

in the Dutch law, hospitals no longer had to submit plans to a central governmental authority, which normally

must grant approval (Ministerie van Volksgezondheid Welzijn en Sport, 2009). As a consequence hospitals

should fully ensure the safety of the construction project themselves, this is an opportunity for the application

of integrated planning methods such as 4D modeling.

Last but not least, conducting a case study about 4D modeling at a Dutch company is a small step towards the

use of 4D models in the Dutch construction industry. Applying 4D models on this specific case is a stepping

stone in conducting case studies on various projects. To convince companies of using 4D models on Dutch

construction projects, companies need to have evidence from conducted case studies. Case studies can serve

as a starting point for practitioners to understand better, how 4D models can be applied on their projects

(Hartmann, et al., 2008).

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

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