By Heidi Schwartz
Published in the January 2004 issue of Today’s Facility Manager
It is a proud moment to complete construction of any building dedicated to providing life saving patient services. But what if that project was one of the most complex heart transplant facilities in the world? Or what if that project required phenomenal levels of communication between two owners, two architectural firms, and two engineering firms? And what if it required coordinating and managing the efforts of the facility management team plus over 100 subcontractors, suppliers, and equipment vendors? If that doesn’t sound challenging enough, imagine what would happen if a natural disaster struck right in the middle of the project?
On the day the new Texas Heart Institute (THI) portion of St. Luke’s Episcopal Hospital opened, internationally renowned medical leaders filed into the new building. In spite of the excitement, appreciation and highest praise went directly to St. Luke’s Director of Facilities and Engineering, Chuck Ayoub*. He had, through great personal sacrifice, accomplished truly amazing things.
The 10-story THI is affiliated with-and attached on one side to-St. Luke’s Episcopal Hospital, which is located in the massive Texas Medical Center in Houston, TX. The building was constructed on three acres at the corner of a busy intersection. The $85 million, 331,000 square foot facility provides an environment that supports surgical services and research related to gene therapy, vascular cell biology, heart failure, heart transplantation, heart assist devices, and artificial hearts.
Construction of this care intensive facility required the support and cooperation of many players throughout the building process. From the onset, Ayoub called together the design and construction teams to meet with the two owners to set goals, outline each party’s needs and roles, and create a truly collaborative environment. The level of communication and cooperation Ayoub was able to instill throughout this process proved invaluable as the team worked through the many challenges to come.
Innovative Thinking Spurs Success
Fast track construction is uncommon in highly complex health care settings, but this approach was essential in a project where the facilities are critical for life saving cardiovascular treatments and research. As a result, all utility relocation and foundation pours (along with a majority of the structure) were completed well before the construction documents were finalized.
Ayoub’s expertise in fast tracking and his strong leadership skills assured the successful coordination of the myriad of details and engineering issues that allowed the building process to continue to speed forward. By successfully fast tracking this incredibly difficult project, the owners saved approximately nine months of development time.
Another time and cost saving innovation that Ayoub spearheaded with the contractor was the development of an e-mail based billing system. The contractor would e-mail each pay application to the architect, who would then review the costs, attach an electronic signature, and forward it on to the owner’s representative. The invoice would then be paid electronically by direct deposit to the contractor’s account.
Judge Maria Vickers notes, “The e-mail based billing system and direct deposit payments kept the contractor financially healthy and motivated, ensuring that work would not be delayed for unnecessary reasons.” She adds, “This was an operational improvement that can and will be continued to improve the overall efficiency of the business.”
This system vastly reduced days outstanding (under 30 days) and was a great benefit for subcontractors who are often faced with carrying labor and material expenses for at least 90 days. The e-mail billing system also proved successful in expediting change orders and dramatically reducing the typical approval time periods.
Judge Alex Lam calls the fast track and e-mail billing “brilliant,” and Judge Tom Condon adds, “The innovative e-mail invoicing system [is] a fantastic way to streamline the payout process, and obviously it improves tracking of payment status on a big job.”
Addressing Long-Term Needs
Heart surgery and transplants often require that a person’s immune system be temporarily rendered inactive. As such, even a small amount of fungus, bacteria, or mold could seriously harm a patient. Just a spilled soft drink could create mold spores that might live in a dormant state for 100 years. Maintaining a sterile environment was the most important long-term need for this project.
As a result, Ayoub made sure that special care was taken in all construction activity to create as clean an environment as possible.
Each piece of duct was sealed at the factory to keep dust out. Upon arrival on site, the ducts were then re-wrapped in heavy plastic to protect them further from construction dust.
Each day, as sections of the duct work were installed, all openings were sealed. A HEPA filtration system was used to vacuum all tracks in the metal studs before drywall was installed. After vacuuming, each stud was wiped down by hand to capture minute debris.
No food or drink was allowed in the building. This mandate was considered so serious that workers faced loss of job if they did not adhere to the regulation. Another important issue was humidity. A humid environment can create a breeding ground for mold, spores, and bacteria. Houston’s typical humidity level rises well above the national average and additional humidity is created in enclosed construction.
Ayoub dealt with this by mandating that no drywall material be installed until the building was fully enclosed. Then, once the drywall was taped and floated, the air conditioning was brought on line, floor by floor, as the interior construction progressed.
This reduced humidity and accelerated the drying of construction adhesives. As the terrazzo floors were installed, all drywall was wrapped in plastic at the base to keep moisture from infiltrating the drywall. This moisture could have resulted in a mold problem if not properly addressed. HEPA filters were installed at all air handling units in an effort to keep the ductwork cleaned and free of airborne microorganisms. Condon observes, “Dealing effectively with the risk of mold shows a real concern for the long-term success of the facility.”
These two examples are merely a portion of a complex Infection Control Risk Assessment procedure developed for this project by Ayoub and his team. These standards are so comprehensive and well defined that they have now been adopted by the Joint Commission for the Accreditation of Hospital Organizations and are used as the standards for all new construction and remodeling projects at hospitals nationwide. The American Institute of Architects (AIA) has also included these procedures within its new AIA Code of Standard Practices for construction and remodeling of hospital facilities.
Vickers says, “The approach to building a sterile and humidity free environment was quite innovative. It balanced the extra time and expense needed for the effort with the long-term requirements of-and benefits to-the facility and its customers.”
Bottom Line Benefits
From the very beginning, Ayoub’s leadership brought improved results. He implemented a development approach that provided the design and construction team with the information, analytical tools, and development/construction knowledge to make informed decisions during both the project planning and implementation phases.
This process nurtured an environment where all team members contributed their individual expertise through co-active participation. The approach helped the architects and engineers to understand project issues from a constructability point of view prior to-and during-design, which minimized plan revisions.
Scheduling was also a crucial component of cost containment. Ayoub’s mandate for conscientious adherence to subcontractor schedule commitments reduced waste and inefficiency and increased productivity. A comparative cost analysis shows that THI’s $185/square foot cost was at least 10% less than comparable facilities.
Ayoub’s leadership in managing the cost environment was further verified by the following example: working closely with the contractor, Ayoub found that construction materials would have average materials price escalations of over 6% throughout the three-year construction process. Of particular concern was the drywall material, which increased in cost by 25%. To address this, Ayoub led his team in the decision to defer drywall purchasing, betting that the market price would come down over time. He invited the drywall contractor to participate in this collaboration and offered an incentive for cost saving initiatives. As a result, the owner saved over $100,000 in material costs.
Condon observes, “The financial results are impressive, and I particularly liked the attention to materials prices (drywall).” Vickers adds, “Involving the contractor in the drywall purchasing scheme was an excellent incentive.”
Human Improvements Result In A Dynamic Facility
In planning the THI facility, Ayoub requested input from the surgical and research teams in order to assure the completed building would indeed provide the highest level of quality patient care. Listening carefully to the staff would prove paramount to the success of the project.
Ayoub developed a communication process in which physicians, nurses, and medical professionals met regularly with the design and construction team throughout the planning, preconstruction, and construction phases. Dozens of three dimensional computer renderings were created of many facility spaces and shared with employees, who then provided detailed feedback in focus group settings.
Full scale mock ups of the operation rooms, ICUs, and the patient rooms were constructed to facilitate hands on input into the design process. The employees’ ideas and opinions helped produce a truly dynamic and award winning facility.
In addition, their input resulted in further bottom line benefit because it reduced the potential for change orders, since renderings and mock ups could be reviewed, revised, and approved before creating construction plans and documents.
Vickers says, “Involving the medical staff in the design process ensured the long-term viability of the building. The three dimensional renderings allowed the medical staff to ‘try out’ the space and suggest the best improvements to accommodate how it will actually be used, thus eliminating the possibility of wasted space. Keeping the medical staff involved in the facility design ensured their satisfaction with-and proper use of-the space. Employees know if a facility is designed with their needs and processes in mind, and this adds to their morale and retention.”
Condon adds, “Using focus groups and other techniques to involve the facility’s customers in its design shows an advanced understanding of the facility as a tool for people.”
According to Judge Tim Springer, “Attention both to stakeholders (owners, users, staff, contractors, and public) demonstrated Ayoub’s management skills. he was able to build a strong, well functioning team, which in turn, enabled a high-level performance under an extremely challenging series of events.”
The Unforeseen Challenges
In spite of careful planning, unfortunate circumstances plagued the project. On February 11, 2001, the roof was on, the building enclosed, and drywall was installed on six floors. The project was on budget and schedule when the team headed out for a weekend reprieve.
Little could they know that a steam line within the building would burst, spewing water, steam, and humidity throughout the entire facility. The rupture was discovered Sunday morning by a member of St. Luke’s engineering staff who then notified Ayoub. His staff immediately took charge. According to the contractor, most in house teams would have simply waited for the contractor to come in and deal with the crisis.
Instead, Ayoub immediately mobilized his team who hurriedly began remediation and clean up, and then worked side by side with the contractor’s team to assess the damage, prioritize the needs, schedule activities, and begin to rectify the situation.
Working closely with insurance and hospital representatives, Ayoub remained fully committed to a policy of zero tolerance for non-sterile construction. As a result, 14,000 panels of sheetrock were removed and replaced. All damaged porous surfaces were taken out, including all insulation, which resulted in thousands of pounds of debris.
It was Ayoub’s strong leadership skills, direct approach to problem solving, and unwavering commitment to excellence that made this seeming disaster a manageable situation. While the accident was a huge setback, the well orchestrated remediation efforts brought the project back on line in just 61 calendar days.
Construction activities returned to a normal pace and project activity continued to remain on budget and on schedule. But four months after the steam line event, a natural disaster hit Houston hard. A five-day tropical storm rocked the city, dropping 41″ of rain; and on June 9, 2001, floodwaters overtook portions of the Texas Medical Center.
St. Luke’s Episcopal Hospital, like most facilities in the complex, was flooded and all its utilities were lost-including emergency power. Ayoub immediately set up a facilities command center. With the countenance of an army general in combat, he brought together the design and construction teams. Armed with wallboard and markers, he outlined a collaborative and comprehensive approach: identified all problems, normalized the situation, and monitored and attacked the critical components.
Ayoub led his in house team and hundreds of subcontractors as they worked around the clock to aid in the effort to bring St. Luke’s back on line. Each day, new goals were set, progress assessed, and work efforts rewarded.
As a result, St. Luke’s was the first flooded hospital in the Texas Medical Center to return on line. The work was completed in just 11 days-an incredible feat considering that some of the other medical facilities were still dependent on temporary systems even four months later.
The magnitude of Ayoub’s accomplishments in this crisis is further underscored by the fact that his own home was devastated by the flood. Therefore, he not only worked night and day to bring St. Luke’s on line and keep construction moving on THI, but he also had to pick up the pieces from his family’s own personal disaster. His focus, commitment, and wisdom were deeply inspiring to the entire team.
“Ayoub’s own self sacrifice during the flood seems to have inspired his team to put forth their best effort,” notes Vickers.
Throughout the trauma and drama of the devastating flooding of St. Luke’s, Ayoub simultaneously kept construction activity moving forward at the adjacent THI. However, the residual effects of the natural disaster, combined with the exhaustion of the construction crews and the hospital facilities staff, resulted in the decision to delay the substantial completion of THI by about two months. During that time, Ayoub led his team in developing efficiencies and creative alternatives that kept the dedication and opening dates on schedule.
Throughout the project, Ayoub accepted a difficult assignment that became more challenging through the three-year construction process. His leadership skills, charismatic ability to create a cohesive team, and ability to make quick, intelligent, and creative decisions under incredible stress attest to the quality of his character and talent.
Springer concludes, “From streamlining payments of contractors to developing state-of-the-art practices and procedures for construction of clean health care treatment environments, to dealing with disasters, Ayoub applied innovation and creativity to all aspects of this significant facility project.”
His compassion and sacrificial efforts make him an unsung hero. The contractors refer to him as “Superman,” an apt title for an amazing man.
*Note: Charles Ayoub passed away in 2013 after a brief illness.
Name: Charles “Chuck” Ayoub, CHSP, director of facilities and engineering
Organization: St. Luke’s Episcopal Hospital
Location: Houston, TX
Years in Facility Management: 30
- Overview: New 10 story, 331,000 square foot Texas Heart Institute
(Ayoub is responsible for 1.5 square feet of hospital space overall),
- Budget: $86 million
- Total Amount Spent: $82.5 million
- Project Time: 33 months (original time budgeted: 42 months)
- Number Of Employees In Company: More than 1,000 (in-house staff: 75-100)
Furniture: Nimes N116 Sage Stone by Atlas.
Storage: Metro. Nurse Call Stations: Hill-Rom Services, Inc.
Patient Bedding: Hill-Rom Services, Inc.
Carpet: Atlas Carpet Mills; Interface.
Hard Surface Flooring: Nora by Freudenberg.
Fabrics/Textiles/Upholstery: Jhane Barnes; Guilford of Maine.
Lighting: T8 with GE Electronic Ballasts.
Lighting Controls: Lutron.
Acoustics/Sound Masking: Modernfold.
Security System: Northern Computers.
Life Safety System: Notifier; Tyco from SimplexGrinnell.
HVAC Equipment: Temptrol; Peerless; Aurora; Johnson Controls.
Building Management/Automation: Metasys by Johnson Controls.
Variable Frequency Drives: Toshiba.
Air Filters: Filtration Group M Series by 2020 Analytical Inc.
Emergency Power: Mustang Power Equipment by Caterpillar.
Emergency Power Switchgear: ASCO; Cutler Hammer.
Power Monitoring: PowerLogic® by Square D. Maintenance
Database: iTMS by Four Rivers Software Systems Inc.
Elevator Systems: Fujitec America, Inc.
Roofing: Performance Roof System/Modified Bitumen from Competition Roofing Co.
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