In all things, planning prevents poor execution. Arguably, the current crisis requires even more deliberate and diligent planning than before to keep patients and employees safe and to guard against lost revenue.
Executing construction projects in and around operating health care facilities has always required a greater attention to detail than most projects, simply because normal byproducts of the work such as dust and noise can yield life-threatening situations. Planning the work to eliminate any unplanned disruptions is integral to this market segment and to being a valued and trusted partner of health care facilities as a construction service provider. In the era of COVID-19, hazards to the adjoining areas and even the contractors performing the work require a parallel process that will not only keep general contractors and construction managers as valued partners, but will help to keep the pipeline of future projects secure for the foreseeable future. Developing, implementing, monitoring and adjusting specific protocols to execute construction—while not increasing the possibility of a COVID-19 infection and subsequent spread to employees and patients—will be crucial to demonstrate that construction projects should continue to go forward.
This article outlines elements of an executable COVID-19 mitigation plan will be offered. While this outline is not meant to be complete and final, it is meant to be a starting point for any director/manager, project manager, infection control professional, superintendent, facility manager or foreman to formulate their plan for feedback from project stakeholders. This article will address the following main elements:
- Contractor and Visitor Screening and Monitoring
- Site Access and Material Deliveries
- Break Areas, Restrooms and Proper Hygiene Facilities
- Special Requirements when Executing the Work
Contractor and Visitor Screening and Monitoring
Before any work occurs, the project team should establish a process and policy that requires any contractor or visitor to self-screen before coming on-site. This could be as simple as a form that everyone fills out, then the on-site construction manager or superintendent validates, files and distributes to pertinent stakeholders. Other facilities require employees to fill out these forms electronically to expedite the filing process. Documentation of self-screening not only requires anyone coming on-site to do a “gut-check” of any symptoms or outside-of-work factors that could put people at risk, it also serves as a way to demonstrate due diligence to OSHA, local health authorities or the like should any questions arise.
Some suggested screening questions are below:
- Do you have symptoms of respiratory infection (cough, shortness of breath)?
- Do you have a fever of 100.4 degrees or higher?
- Have you had any contact with a person with a confirmed case of COVID-19 within the last 14 days?
- Have you traveled within the last 14 days to countries or other areas of concern as noted by the CDC or local travel restrictions?
- Have you been tested for COVID-19 and are waiting for the results?
It should be made clear answering yes to any of these questions will require the employee to immediately leave site. Then, the project management team should determine what the proper response measures should be to allow the employee to return to work at a later date. It could be as simple as requiring the employee to self-quarantine for 14 days and to be symptom-free before returning. Or, it could be as conservative as requiring two consecutive negative COVID-19 tests. This will depend on the risk tolerance of the facility where work is occurring.
In addition to screening, monitoring employees and their health is crucial. It is entirely possible that a contractor will arrive at work symptom-free, then develop one or more symptoms as the day progresses. The project should have a documented and communicated response plan prepared for such an event. Please refer to the ASHE COVID-19 Resources webpage for guidance on how to develop this plan and key elements associated with it.
Site Access and Material Deliveries
While most health care construction projects tend to plan out material and access routes in advance to avoid cross-contamination between contractors and patients, this process must be taken one step further to avoid the same between contractors and support/clinical staff. A specific, contractors-only entrance could be dedicated to aid in limiting unnecessary contact. This will provide the added benefit of centralizing the entrance point of contractors, allowing the project management team to ensure that all contractors are screened when entering the facility.
If work is occurring on upper levels of the facility and will require elevator use, a single elevator should be designated for construction use. If a single elevator cannot be designated, then alternate means such as buck hoists, material lifts or the like could be explored. Additionally, the working hours of the project could be shifted such that peak hours of contractor elevator use would not coincide with general elevator use. Furthermore, occupancy of the elevator should be limited such that social distancing can be maintained.
When coordinating construction material deliveries, drop-off locations should be selected that will limit interaction with the facility’s deliveries. This could be the same designated contractor entrance as previously discussed. It is good practice to require that all deliveries be scheduled at least 48 hours in advance with the on-site project representative so they can coordinate with the facility and ensure that no conflicts exist. Additionally, deliveries could be scheduled during off-hours when normal dock traffic is either minimal or not anticipated. It is crucial that delivery drivers be screened and not be allowed to leave the cab of their vehicle. Remember, the goal is to limit any unnecessary interactions.
Break Areas, Restrooms and Proper Hygiene Facilities
In the past, construction projects haven’t spent a great deal of time ensuring that contractors have the ability to properly sanitize their hands. It isn’t uncommon that a communal bottle of hand sanitizer was the only consideration offered. However, combatting COVID-19 has required that special attention be paid to providing facilities that ensure job site conditions allow for all CDC guidelines to be followed.
First, a single men’s and women’s restroom should be designated as construction use only. It should be made abundantly clear that contractors should not use any other restroom. If one is not available in the general facility, it may be necessary to bring in temporary toilets or even a toilet trailer, which is usually a safer and better option. If temporary toilets must be used or domestic, potable water is not available, hand-washing stations should be procured for use by contractors. It is crucial that the project team plan for daily cleaning and stocking of consumables to keep these facilities safe and functional.
Break areas should also be specially designated for contractors. Since cafeterias are already operating at reduced capacity, these could be a potential contact hazard area, and if their location will require contractors to travel through public and patient care areas to access them it may not be advisable to allow contractors to take break in these locations. Separate areas such as shell spaces, temporary office trailers, outdoor picnic areas, or even in the job site itself could be utilized. These should be selected based on the peak manpower projected on-site and the associated area required for these contractors to take break while maintaining social distancing. If the cafeteria remains the only viable option, then an area could be cordoned off to prevent any unnecessary contact.
In addition to having separate designated break areas, use of these areas should be well thought out. For instance, staggering breaks to avoid overloading the space has been successful in ensuring social distancing can be maintained. Additionally, sanitizing these areas after each use is necessary to be in compliance with CDC guidelines. It is recommended that the general contractor or construction manager be responsible for providing the labor, equipment and supplies to ensure sanitization happens regularly. Another often overlooked item is ensuring that drinking water does not become a hazard point. It is recommended that individual, disposable water bottles be provided instead of water coolers, drinking fountains or drink coolers.
Special Requirements when Executing the Work
Planning for safe projects isn’t limited to logistics, restrooms and break areas. Scheduling projects to avoid the “stacking” of trades in which social distancing cannot occur, ensuring shared tools and equipment are properly and regularly sanitized, and instituting special PPE requirements when tasks cannot reasonably allow for social distancing will also keep contractors, clinical staff and support staff safe.
Project schedules should either be created or reevaluated with the goal of sequencing the work to limit peak manpower. This should be based on what can be reasonably managed while maintaining social distancing, complying with CDC guidelines and the risk tolerance of the facility in question. It is likely that the overall project duration will be extended. Therefore, this should be done collaboratively by all project stakeholders to ensure that financial and duration goals are met. Special attention during the bidding and contracting process to understand each subcontractor’s and trade contractor’s duration and crew size to complete their scope of work will be crucial by the general contractor/construction manager.
If the project will have communal equipment such as lifts, fork trucks or the like, it is recommended to keep a disinfecting solution and rag onboard (similar to that at a gym) so that it can be disinfected after each use. Crews that share tools should also clean them daily after each shift and power tools should be cleaned in accordance with the manufacturer’s guidelines. It is recommended that daily activity planning forms (commonly referred to as Job Safety Analyses (JSAs), Task Hazard Analyses (THAs) or the like) be adjusted to include this hazard and make sure that requirements are well communicated to each person on the crew.
Since it is likely that certain tasks will not reasonably allow for social distancing, the project team should define special PPE requirements in advance to avoid frustration, lost time and potential transmission risk. This could include controls such as N95 or P100 rated respirators, face shields, gasketed safety glasses or the like. Infection control practitioners can provide feedback on these work practices. If standard work practices cannot address the hazards associated with a specific task, contractors should be notified that these instances should be reviewed well in advance. Diligent planning in advance of work occurring on-site is the key to keeping contractors safe and healthy.
In conclusion, construction of critical infrastructure such as hospitals has been designated an essential service. Keeping these projects viable, safe and operating will require a well thought out and documented plan. ASHE (and several trade organizations) offer many resources to set project teams up for success. Implementing these plans in a collaborative manner, seeking feedback from all stakeholders in the pursuit of continuous improvement, and holding everyone accountable to keep each other safe will increase the likelihood of success. Furthermore, maintaining a positive attitude and ensuring actions match words will sell the credibility of these plans such that everyone will voluntarily comply with the necessary guidelines.
Adam Ashouri, is senior project manager at Messer Construction Co. and ASHE young professional member, and Benjamin Leutze, is senior advocacy associate at American Society for Health Care Engineering and ASHE young professional member.