1 Hospital Design and PPP in JAPAN“APPLICATION AND RESULTS IN HEALTHCARE IN TURKEY, PARTICIPATION OF LOCAL PRODUCERS-OFFSET APPLICATIONS” Hospital Design and PPP in JAPAN May 09th, 2013 Hiroyuki TSUCHIYA (1st Class Registered Architect) General Manager ITEC (International Total Engineering Corporation) Thank you very much for inviting us to this seminar today. My name is Hiroyuki Tsuchiya from ITEC. In my part, I would like to introduce "Hospital Design and PPP in Japan“. Japan Association of Health Service Management Consultants Certified Health Service Management Consultant Corporation (No ) 1st Class Registered Architect Office (No.24666) Total Health Service Management Consulting Firm INTERNATIONAL TOTAL ENGINEERING CORPORATION
2 About ITEC The first consulting firm in Japan specialized in the hospital and healthcare field. Established in 1981 Ratio of Sales Amount [2012] Domestic 50% Overseas 50% Experiences Domestic： more than 700 contracts Overseas： more than 70 countries Overseas Offices Ankara Office (Turkey) Baghdad Office (Iraq) Overseas Experiences First of all, let me briefly introduce our company. ITEC was established in 1981 as the first consulting company in Japan specialized in the hospital and healthcare field. And today, we are one of leading consulting companies in Japan providing services worldwide. In Turkey, we have office in Ankara. And we are working health campus PPP project as a consultant in the エトリック and イキテリ together with NKY. Apart from Turkey, we also have an office in Baghdad and providing consulting services for the Ministry of Health in Iraq. Homepage
3 ITEC’s PPP Hospital Consulting Experiences in JapanTokyo Metropolitan Tama Medical Center (750 beds) Tokyo Metropolitan Children's Medical Center (600 beds) Ehime Prefectural Central Hospital (823 beds) Tsukuba University Hospital (800 beds) Fukuoka Children's Hospital& Medical Center for Infectious Diseases (200 beds) Saga HIMAT (Heavy Ion Beam Therapy Center) Tokyo Metropolitan Cancer and Infectious diseases Center (801 beds) Tokyo Metropolitan MATSUZAWA Hospital (897 beds) Nagasaki Municipal Hospital (500 beds) As in this slide, these are our major consulting experiences of PPP hospital projects in Japan. ITEC has No.1 consulting experiences in Japan, in terms of number of hospital as well as the size of projects. From the next slide, I would like to explain the Japanese hospital design, then Japanese PPP.
4 Characteristics of Design Trend in JapanKey Design Trends Key words & Technologies applied Operational Efficiency LCC (Life Cycle Cost) approach (→ Energy Saving Technology) Disaster Measure BCP (Business Continuity Plan) → Seismic Isolator Today, I would like to introduce two keys of design trends in Japan. One is “Operational Efficiency” The Other one is “Disaster Measure” For operational efficiency, I would like to explain importance of Life Cycle Cost approach for hospital project. And for Disaster Measure, I will introduce characteristic planning approach and some technology in Japan.
5 Breakdown of Life Cycle Cost (15years)Initial Cost 20% Operational Cost 80% Firstly, I would like to start with importance of Life Cycle Cost approach for hospital project. Hospital consumes heavy amount of cost in operation. Because it runs 24 hours 7 days with expensive equipment stand-by, and it cannot be stopped basically. So, “Life Cycle Cost” approach is more important than initial cost when you design hospitals. Please look at this graph. This graph shows the breakdown of the total Life Cycle Cost for 15 years of the hospital PPP project in Japan. Among the total cost, ＊アニメ1＊ the Initial Cost is about 20%, on the other hand ＊アニメ2＊ the Operational Cost is around 80%. You can understand how the Operational Cost takes most of the Life Cycle Cost. Reference : Tama Medical PFI Corporation
6 Life Cycle Cost Private Sector’s Life Cycle Cost Know - How ↓ VFM(Value for Money) Life Cycle Cost Running Cost The most important target of hospital PPP is reducing Life Cycle Cost. Of course, achieving good value of medical care service is also important. This slide is just an image, but If Private Sector’s Know-How can reduce Life Cycle Cost, reduced amount is called Value for Money. We call it VFM. VFM is the key indicator whether you decide to go on PPP scheme or public sector by themselves. In Japan, many ideas and technologies to reduce Life Cycle Cost are applied. One of the design trend is so called “Ecology Hospital”. Initial Cost Public Sector Private Sector
7 The Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility ■ Environmentally Friendly Hospital ■ Long Life Building Eco Item Measures 1 Leave the Nature Taking advantage of the existing geographical feature, unnecessary cutting and the soil discharge are avoided and maintain ecosystem . 2 Natural Lighting / Natural Ventilation Natural lighting and wind are taken by using the open ceiling. 3 Tree Planting Plant trees on the building roof or hang grass in the exterior. 4 Solar Generation Hybrid outdoor power generation light is installed to the outdoors. 5 Thermal Solar Control the amount of the gas used by the hot-water supply of thermal solar conversion. 6 Rain Water Storage rain water is used for washing of toilet or watering of plant. 7 Energy Management Use of BEMS 8 Use of Quake-Absorbing Layer Use as cool pit and warm pit. 9 Effective Use of Heat Hot water supply by heat discharge of boiler 10 Highly Efficient Glass Adoption of the high double-glazed glass for the air-conditioning load mitigation effect. 11 Exterior Louver Direct rays are intercepted externally. 12 Long-life Building Frame Arrangement of spare sleeve for MEP piping to steel frame beam. 13 Skeleton Infill The dry type method is adopted which divides building frame and interior material. 14 Eco Materials Natural material and recycling material are used for finishing. 15 Water-saving Equipment Use of automatic foucet. 16 Lighting Control Use of motion sensor and daylight saving 17 High Efficiency Equipment Use of top runner transformer, LED light 5. Thermal Solar 2. Natural Lighting / Ventilation 15. Water-saving Equipment 14. Eco Materials 16. Lighting Control 6. Rain Water 11. Exterior Louver 10. Highly Efficient Glass 17. High Efficiency Equipment 3. Tree Planting This slide shows planning image of Ecology hospital. I would not mention detail measures here. But important point is to plan the hospital design how far you can reduce “Life Cycle Cost” and what kind of technologies are applied for this. ************************************************************* Keep the nature, Natural lighting, Tree planting, Solar power generation, Solar thermal conversion, Rain water use, Energy management, Effective use of heat, Highly efficient glass, external louver, Long-life building frame, Skeleton infill, Eco materials, Water-saving equipment, Lighting control 7. Energy Management 4. Solar Generation (Hybrid PW generator) 1. Leave the Nature 12. Long-life Building Frame 9. Effective Use of Heat 13. Skeleton Infill 8. Use of Quake-Absorbing Layer
8 Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility Frequency of Earthquake / Number of Death Victims （1980～2000） Number of Disaster Death Victims (persons / year) Frequency of Earthquake (times / year) China Indonesia Iran Japan Afghanistan Turkey Mexico India Pakistan Peru Greece Philippines Italy Colombia USA Ecuador Algeria Costa Rica PNG Russia Chili Guatemala Bangladesh Guru Zia Bolivia Australia South Africa Venezuela Nicaragua Armenia Frequency of Earthquake → Well, from this slide, I would like to mention trend of “Disaster Measure”. As you know, Japan is famous for one of the アース クエイク countries in the world. At the same time, we understand Turkey is also suffering from the アース クエイク damage. So our past experiences and design trend may be able to applied to hospital design in Turkey. ← Frequency of Earthquake per Country’s area / 380,000km2 1,190.5 0.63 0.05 Earthquake frequency is earthquake beyond magnitude 5.5. (Source: UNDP)
9 ■ BCP (Business Continuity Plan)Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility ■ BCP (Business Continuity Plan) Concept to continue hospital critical operation even at the time of disaster Japanese hospital design is historically effected by past tragic experiences. One of the key concept of hospital design is so called Business Continuity Plan. We call it BCP. And this concept has become even more important since Great East Japan アース クエイク struck in 2011 with Richter Scale Magnitude 9.0. BCP (Business Continuity Plan) is the design concept to continue hospital critical operation even at the time of disaster. In the time of disaster, public infrastructure, like electricity, water, gas and telecommunications are damaged for weeks or several months. Public transportations like road and railways will become useless with damage and panic. But even such conditions, medical facility cannot be stopped or even damaged. Because, hospital is the last resort for citizen at the time of disaster.
10 Great East Japan Earthquake in 2011,Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility Great East Japan Earthquake in 2011, And this is something going to happen in the hospital at the time of disaster. Hospital will be packed by patients and their families, international medical teams and so on. Available space like waiting area and corridor will become treatment area like in the picture. Reference : Ishinomaki Red-Cross Hospital
11 World First Life Continuity Building supporting BCPThe Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility World First Life Continuity Building supporting BCP Item Contents Location Shizuoka Pref. Kakegawa City, Japan No. of Bed 500Beds, 26 Beds (Special) No. of Service 32 Healthcare Services Site Area 137,200 ㎡ Building Area 11,300 ㎡ Floor Area 44,000 ㎡ Stories 8 Stories (No Basement) Building Height 38.9 m Structure Steel Structure (Anti-Seismic) No. of Parking 730 (Public), 770 (Staff) Site Plan Break Down of 500 Beds 4 Beds Rm. 328 Beds 2 Beds Rm. 12 Beds Single Rm. 141 Beds Others 19 Beds Now, I’d like to introduce the latest example hospital in Japan, just opened the last week. We, ITEC, are consultant for this project and The name of hospital is Kakegawa hospital, and bed capacity is 500 beds. This hospital is the world's latest Life Continuity Building, which is wider concept of BCP. Location of the hospital is in the area of the Tokai アース クエイク. ＊＊＊＊＊＊＊＊＊＊＊＊＊＊＊＊ BCP mainly focus on Business, in other words, hospital operation. Life Continuity Plan extends BCP concept to normal daily life of citizens around the hospital. Public Entrance Emergency Entrance
12 Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility Use Parking Space for Support Space to Helicopter (Disaster Time) Stock Storage for Disaster Multi-Patient Room to support increase Bed in case of emergency Window Sash not crashed by deformation Heri-port for Patient Transport (Service in Usual) Anti- Seismic for Energy Center Maintenance Balcony for protect to fall the glass Self Generation System Secure Triage Space in case of Disaster Oil Tank Anti-Seismic Structure more than standard Daylight & Ventilation for Treatment Space in case of Disaster Enough Water Capacity in case of Disaster Distilled Rain Water in case of Disaster Spring Water in case of Disaster Double Intake Power Line (Continuous Power Receiving) These are major disaster countermeasures used in the hospital. I will not mention detail measures, but this hospital is designed to supply energy, water, drainage even at the time of massive アース クエイク. And, hospital is designed to accommodate 3 times more outpatient at the time of disaster. ****************************************************************** ・Fall preventive measures of all the equipment such as the window sash which follows in footsteps of a large-scale quake-absorbing structure and is not destroyed by distortion. ・Introduction of special technique for the ceiling which prevent the fall of lighting fixtures and mechanical equipment. ・Water supply reservoirs of 140 ton for drinking water and 350 ton for other water supply are secured. ・Using well water for miscellaneous such as toilet washing at the time of a disaster. ・A 700 ton of sewage storage tank is secured in case of sewer infrastructure is suffering a damage being unable to drain. ・Securing sufficient capacity for the oil tanks, generating electricity, power backup equipment and preparing for the medical treatment in an emergency. ・It extends the supply period for maximum of 20 days with saving electricity ********** MAIN FEATURES ♣ Fall preventive measures follows in footsteps of a large-scale quake-absorbing. ♣ 140 ton of water supply reservoirs for drinking water and 350 ton for other water supply. ♣ Using rain water and spring water for miscellaneous use. ♣ 700 ton of sewage storage tank in case of sewer infrastructure is suffered. ♣ Sufficient capacity for the oil tanks, generating electricity ♣ Extends the supply period for maximum of 20 days.
13 Hospital Design and PPP in JAPAN Divertible floor plan for disaster case Entrance Hall ↓ Triage Space In each floor plan for example. At the time of disaster…, - Entrance becomes “Triage Space”. - And Hospital mall becomes “one huge treatment space”. - Consultation room and waiting area is designed to become base station for backup staff.
14 Hospital Design and PPP in JAPAN Trend of Japan in Medical, Health Facility 4 Bed Room Hospital Mall Let’s see in these visual images also. The hospital mall is converted to one big treatment areas. Patient bed room can accommodate additional beds, from ordinally 4 bed room into 6 bed room. The lower picture is an example of Emergency Medical Gas Supply outlets. These are installed every areas like hospital mall, corridors, auditorium and so on. Emergency Medical Gas Supply
15 Building with Seismic Isolator Building without Seismic IsolatorHigh Level Seismic Isolation System for BCP Of course Seismic Isolator is also installed in Kakegawa hospital. In Japan the first seismic isolated building was established in 1983. So we have 30 years of experience with this technology. Building with Seismic Isolator Building without Seismic Isolator Life saving , reducing of structural damage and minimizing secondary damage to equipment inside the building Reference : Shimizu Corporation
16 Viscous Body Damper in Brace Type Seismic Isolated Members ・Bearing: Absorption of Shock or Rolling Natural Rubber Bearing Natural Rubber Bolt Hole Inner Steel Plate Cover Rubber Steel Flange Plate Slide Bearing Stainless Steel Plate Steel Flange Plate PTFE Slide Material Rolling Bearing ・Damper: Absorption of Earthquake Energy Outside Pipe Movable Pipe Inside Pipe Viscous Body Steel Damper Oil Damper Viscous Body Damper in Brace Type ・Bearing + Damper I would like to introduce some Seismic Isolation technology which is commonly used in this hospital. ＊アニメ1＊ ♦Bearings, these support the building under the basement over the foundation. These devices act as shock absorber or rolling absorber of the foundation of the building. ＊アニメ2＊ ♦Dampers: these are absorption of the アース クエイク energy. ＊アニメ3＊ ♦Bearing + Damper: Carry the building on the stand which can move in the horizontal direction freely. Since the building is heavy, even if the ground moves quickly it moves slowly. Base-isolating device is to make this possible. Natural Rubber Lead Plug Inner Steel Plate Cover Rubber Bolt Hole Steel Flange Plate Lead Rubber Bearing
17 Led strongly by Public Sector Limited Private Sector’s know-howExperience and Evolution of Hospital PPP in Japan 1999 : Enacted PFI law 1st Generations 2nd Generations 3rd Generations 3 years 3 years Ex. Kochi Medical Center * BOT 28 years Ex. Tokyo MTP Tama Medical Center * BTO 15 years Ex. Tsukuba University Hospital * BTO 20 years Led strongly by Public Sector ↓ Limited Private Sector’s know-how Detailed Operation Planning Between Public & Private Became Partnership Between Public & Private So far mainly I had technical talk. Now I’d like to introduce Japanese PPP experience and important factor for success. ＊アニメ1＊ In Japan the PFI law was enacted in 1999. ＊アニメ2＊ In the 1st Generation of Japanese hospital PPP, they were strongly led by Public Sector. The utilization of Private Sector’s know-how was relatively limited. ＊アニメ3＊ Then improvement has been done in the 2nd Generation. But still, there were some gaps among Public Sector and Private Sector about the scope of operational works. And continuously, improvements have been made. Now we have 3rd Generation. Tsukuba university hospital is major project in this generation, and just opened last year. Japanese PPP hospital has 15 years of experience so far, and we understand spirit of partnership among public and private sector is the most important factor for success. * Announcement of Implementation Policy