Proceedings of the 29th Annual International
Conference of the IEEE EMBS
Cité Internationale, Lyon, France
August 23-26, 2007.
THE ROLE OF THE CLINICAL ENGINEER IN THE DESIGN OF NEW
HOSPITALS
M. Decouvelaere, E. Berrard, D. Fabrega,
Abstract — Hospital construction projects take place over
several years, from the initial decision to build to their
completion and start of service. The owner and his
building and civil engineering department have to face
many administrative processes and complex techniques.
It is the role of the clinical engineer to furnish the new
structure with medical equipment, by integrating the
constraints of these devices in the building. At each stage
of the building process, the clinical engineer must
contribute to a specific mission of interface between the
building and the equipment, identifying and anticipating
constraints, and taking care of the good preparation of
the integration of this equipment in existing buildings or
buildings yet to be created. If the objective of optimal
compatibility between the building and its equipment is
not reached, then adaptations will have to be carried out
either in progress, or after the completion of work, and
will be opposed to the factors of success implemented by
the actors.
I. INTRODUCTION
T he Civil Hospitals of LYON (HCL), second University
Hospital complex in France, is currently experiencing a
period of important transformations in its buildings.
Like all hospital complexes, HCL are basing this on their
establishment project, which commits the institution over the
period 2005-2010.[1] The establishment project specifies the
axes of evolution which the institution will be implementing
in the following fields: social projects, project of care,
finances, information systems, and technical projects. HCL
actually have a great deal of work to carry out over this
period, which will transfigure the current hospital landscape
in Lyon. Thus, during this time, new buildings will be
constructed in three of the four hospital groupings of the
city: these will house a centre for biology, a new technical
platform, and new patient wards: in total, HCL will invest
900 million euros for building work and 65 million euros for
biomedical equipment in this project to modernize its estate.
We will explain here the role of the clinical engineer in the
design of a new building through the collective experience
of the HCL clinical engineering services, and according to a
M. Decouvelaere is at present President of the French Association of
Clinical Engineers (A.F.I.B.). She is with the Hospices Civils de Lyon,
Lyon, 69373 FRANCE (tel: (33)472-11-7234; fax: (33)472-11-7287; (e-
mail: martine.decouvelaere@chu-lyon.fr).
E.Berrard, is with the Hospices Civils de Lyon Direction des Affaires
Economiques, service des Techniques Biomédicales, 45 Rue Villon 69373
Lyon Cedex 08. (e-mail: eric.berrard@chu-lyon.fr)
D.Fabrega is at present Clinical engineer , with the Hospices Civils de
Lyon Hôpital Edouard Herriot, 5 place d’Arsonval 69437 Lyon Cedex 03
(e-mail: Danielle.fabrega@chu-lyon.fr).
1-4244-0788-5/07/$20.00 ©2007 IEEE
FrA10.7
stage of different advance according to the hospital grouping
concerned
II. DEVELOPMENT
A. The problem
The analysis of the operating mode of the engineering and
clinical engineering departments shows that responsibility
for investments, ordering practices, and management of
budget accounts are completely separate, that the processes
and actors implemented to build a new hospital are complex
and long (ten years for the building, as against
approximately three years for the equipment).[2] [3] The
direct consequence of this analysis is that the actors will be
unaware of each other, one having the objective to build, the
other to equip, each according to his own criteria of success.
But when the problems of compatibility between building
and equipment are tackled only after completion of the
building, they necessarily generate corrective measurements,
delays, and harmful effects for the completed building. For
certain types of very technical operations, the program of
architecture and engineering is the direct consequence of the
choice of equipment, and neglecting, or even separating
building management from equipment management can
seriously harm the success of the operation.
The building and civil engineering department in charge of
completing the construction of these buildings commissions
on each one of these great projects a full time civil engineer
to manage the project. On the other hand, the Clinical
engineering Department has dedicated a specific engineer to
monitor the great projects, only for specific phases.
This choice reflects the will to make each great project
benefit from the knowledge base of the engineers stationed
on the various sites. A project must be enriched by its
members’ professional experience, not developed without
regard for practical realities.
This decision is also based on the observation of extreme
fluctuations in requests for clinical engineering work and the
resulting workload. It should be recalled here that a building
construction project from design start of service is stretched
over ten years, with phases of intense contribution but also
phases of "silence" devoted to arbitration, studies or
consultation with companies: the workload alone cannot
justify the assignment of a full-time engineer to the project.
It must be acknowledged today that, for lack of dialogue
between the engineering and clinical engineering
departments, the latter department’s contribution is seen as a
constraint: there is little forward planning in the workload,
replies are requested at short notice...
This shows that the overseeing of a great project inevitably
takes place to the detriment of the more traditional activity
of the department.
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 B. The Plan
The study will relate initially to the various phases of the Establishment Voted by board of
legal
authorities
project directors
realization of the hospital building project. Then, based upon year N
the HCL clinical department’s collective experience, we will
illustrate the contribution of the clinical engineer to the Medical Project social projects
design of a new hospital at each stage of the project. We will
project of care information systems
highlight one of the major difficulties, namely the distortion Hospital
master Plan
between the calendars of the two services which too often year N+5
Owner

leads to make choices about equipment and technology too P Specialist

Objectives
early. R
O
faisability
studies Legal authorities approbation
G Summary programme :
R Financial studies
A Program
M Concertation
Detailed Technical Program
C. Processes related to the building phase

In order to describe the interface between the building and year N+7
Project
manager Architectural
the equipment, it is advisable to briefly go over all the S
T
contest
outline
U
phases necessary, over approximately ten years, to complete D Clerk of Summary
I work Project
a hospital. A hospital architectural project originates in the E
S Detailed Project

Regional Healthcare Organization Program, [4] [5] [6]takes R

E Technical
Controller
concrete form within hospital building and restructuring A
L
I
plan, is translated into a Detailed Technical Program, before Z
A Realization of the work - Building site
being realized and brought into service afterwards by a T
I
Technical
participants
O
project manager and technical participants. Figure 1 gives a N
Figure 1 : chronological
outline of the stages
chronological outline of the stages involved in setting up Year N+10 Reception

operations of design then of realization of a hospital.[7][8]

The difficulties to which hospital construction projects are
subjected are mainly related to economic risk factors,
overspending and risks inherent to the financial arrangement
(in particular with regard to surfaces), risks related to
fruitless tender, inconsistency between the price ratio used
and the nature of the surface taken in reference. They also
comprise technical risk factors, such as difficulty in
coordinating different technical trades, the difficulty of
acceptance of the works and technical installations, the
complexity and rigor of the procedures, the difficulty in
modifying the programs, and consequently in adapting the
building to its equipment after acceptance. Any unforeseen
D. Phases of contributions from the clinical department
There are many phases in the development of a new hospital
complex, from the definition of the medical project to the
reception of the first patients. The sequence of these phases
requires a project duration of ten years or more, depending
on the size and complexity of the project. This section will
outline the clinical engineer’s role at the different stages of
the project.
Figure 2 : The main stages of the
Clinical Engineering and
Owner

source of work causes overspending and delay putting into Building Engineering
collaboration Building and Civil Clinical Engineering
service, which are very detrimental in particular when Engineering
Department
Department

transferring patient wards. Establishment project PROGRAM

equipment program,
The Detailed Technical Program phase is an important
specific constraint definition,

clarification of the responsibilities between the building and
prerequisite in defining the constraints induced by the PROGRAM :
Detailed Technical Program
clinical departments,

reading the technical and architectural specifications of
phase
equipment, as the associated buildings and technical the building and the room detailed cards

elements (including civil engineering constraints, networks STUDIES : VERIFICATIONS

Architectural contest
validation and correction of the plans with reference to the
electrical supply, hydraulic, gas, data processing, powers, outline
Summary Project
planned equipment and its relating constraints

check whether working perimeters for equipments are
climatic genius...) will be determined at this time, so that Detailed Project respected.

they are taken into account before the architectural contest FINALIZATION OF THE BIOMEDICAL
and project management which will define the surfaces and REALIZATION :
EQUIPMENT PROGRAM,

Planning and purchasing the new
costs of the building.[9] Reception equipments,

meetings and visits of the building,

Planning the installation of equipments,

Planning the transfer of equipments,

Réception, starting.
10 years
3 years

The first stage consists in working out the medical project

of the future hospital. The methodology adopted within
HCL, which is piloted by the Strategy Department, consists
in making an inventory of medical activities, to evaluating
strong and weak points and situating them in relation to
competing players. Action plans for each medical specialty
emerge from this assessment: grouping activities on the

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same site, increasing material or staff resources, or
abandoning certain activities. The assessment is of course
based on the current pay conditions for medical activities.
The medical profession is the main agent at this stage. The
clinical engineer is occasionally questioned on the effects of
a medical choice on the technical platform.
A final document describing the future hospital’s activity
specialty by specialty is produced, which forms the basis of
discussion throughout the remainder of the project.
The second stage consists in the building owner’s working
out the program. This mission, entrusted to a specialist,
includes a preliminary phase of feasibility analysis and an
operational phase of program development. The program is
the reference document for the building owner’s order from
the project manager. The evaluation of the programcommits
the future of the hospital and often last longer than the
building work itself. There is a permanent dialogue between
the building owner, the legal authorities, the engineering and
technical design departments and representatives from
various hospital departments, with a view to integrating all
the participants’ constraints in terms of space,
functionalities, time and finances. This dialogue on the
functionality of the buildings takes place in interdisciplinary
groups where; doctors of course take part, as do paramedical
personnel, hygiene and working conditions department
experts… Being integrated into these working groups is an
opportunity for the clinical engineer to take in very early on
the evolutions in medical practices and the functionalities
expected in the new building. The debates between different
participants, but also among doctors themselves, are often
intense. The clinical engineer makes a more active
contribution from this stage of the project onwards. His or
her transverse knowledge of the hospital, primarily through
the technical platform, makes it possible to bring a
decompartmentalized point of view to the working group on
the technological developments or the consequences of an
organizational choice.
At the time when the program "is stabilized" by means of the
detailed technical program, the clinical engineer makes a
second reading, targeted on the technical and architectural
specifications of the building and on the room detailed cards.
This work is only possible if the engineer has in parallel
established a preliminary equipment program (on the basis
of a provisional preliminary program) which must then be
re-examined and validated with the users at a more advanced
stage of the project. It appears indeed difficult to solicit users
for the equipment ten years from the opening of the new
building. The difficulty in this type of project consists in
managing two scales of time: ten years for the building
against two or three years for the equipment. On the same
issue of time, the clinical engineer must take care not to be
locked in current operating but leave an opening for the
integration of new technologies at the time of the opening of
the building.
In practice, the second reading of the detailed technical
program is a race against time for the clinical engineer. His
expertise and practical knowledge must enable him to go to
the point: reference to the current legislation, knowledge of
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the general and specific constraints of installation,
clarification of the responsibilities between the building and
clinical departments, validation of the technical elements
envisaged in the room detailed cards. We will see below the
necessity to classify the equipment in three categories as of
this stage, according to the degree of complexity involved in
their installation. It is the clinical engineer’s responsibility to
express his observations, transmit them to the programmist
and to ensure they are taken into account. It is essential in a
project of this scale and duration to formalize the process of
information exchange in order to guarantee the continuity of
engagements between interlocutors.
It is obvious keeping a balance between the formalism
necessary to the advancement of the project and the margin
of uncertainty necessary to facilitate technological
development is a difficult exercise.
The third stage consists, on the building front, in choosing
a building owner on the basis of an architectural project. The
studies are refined while passing through the building
owner’s stages of validation, in keeping with the detailed
program. The studies define the principles of construction,
the levels of technical equipment, the types of materials, the
operational methods and the completion deadlines.
Blueprints help users visualize the development of the
building. In practice, the development of the medical
program can then start with the users, on the basis of the
preliminary program carried out by the clinical engineer on
his own at the preceding stage.
The contribution of the clinical engineer consists here in
validating and correct the plans with reference to the planned
equipment and its relating constraints. At the preceding
stage, we mentioned the need for distinguishing three
categories of equipment: equipment without constraints,
equipment with known generic constraints, and equipment
whose constraints will be known only at the time of the final
choice of equipment. It is advisable here to check that the
interface requirements were indeed taken into account for
categories 2 and 3. It is also necessary to check whether
working perimeters for equipments are respected.
Modifications related to new technologies or the maturation
of the medical equipment program with help from the users
must appear at this stage of the study.
The rule of formalization of exchanges remains necessary
here for observations and corrections to be brought to the
documents transmitted by the project manager.
The fourth stage is the actual realization of the work. Co-
operation is now done on the ground in the form of meetings
and visits of the building site to detect constraints not taken
into account or buildings not in conformity.
At this stage, all the known requirements are translated in
the construction of the building. No new element can in
theory being taken into account in the phase of realization
without inducing additional delays and costs. However, the
clinical engineer, who has only just finalized the biomedical
equipment program, has not yet transmitted all of the
constraints related to the equipment. Indeed, he initiates the
procedures of equipment purchase on the one hand, and
validates the list of existing equipment to be transferred on [8] Philippe Estingoy – Michel Rabatel. Prévenir les risques d’une
opération de construction. 130 fiches d’aide à la décision. Collection
the other hand. As we indicated previously, the clinical Méthode. Le Moniteur. 2006
engineer’s timetable of action is shorter than that of the [9] Mission Interministérielle pour la Qualité des Constructions
building project. Anticipating the action of the biomedical Publiques. Fiche 14-1.Concours de maîtrise d’oeuvre dans le cadre du
side to avoid modifying work at the end of the project can be nouveau Code des Marchés Publics 2006. Septembre 2006
tempting at first, since this would eliminate the margin of
uncertainty related to the equipment. This approach can be
defended neither by the clinical engineer nor by the users
because it would consist in solidifying technological choices
several years before the building is put into service. It is thus
necessary to put up with the reality of the situation:
integrating the constraints of the equipment most likely to
evolve while limiting their number. For that, a method of
screening was worked out by the HCL clinical service in
order to accompany the building project.

III. METHODOLOGICAL ASSISTANCE TOOL

The number and importance of building projects within HCL
for the last five years have given rise to the idea of
developing a database of equipment installation constraints
in order to be provide more speedy and relevant answers to
our interlocutors.[3] The advertised objective was to be able
to provide for each type of room the equipment to be
envisaged with its constraints. The first stage consisted in
collating all the information resulting from the industrial
development programs of the various projects HCL
reorganization projects to to draw a single base: the data
were agglomerated using computers but a second reading
was essential to eliminate duplicate entries. The second stage
consisted in creating a reference frame of installation
constraints per equipment. Various technical points were
worked out with the help of the clinical staff’s experience:
obstruction, air-conditioning, reservations on standby... for
each coding of equipment. The creation of the reference
frame of constraints does not mean each entry is complete!
The volume effect to date did not make it possible to
supplement this data base... let alone updating information.

REFERENCES
[1] Présentation synthétique du projet d’établissement 2005 – 2010 des
Hospices Civils de Lyon. le Journal Interne HCL TONIC, Private
communication, 2006.
[2] Philippe Estingoy – Michel Rabatel. Montage et suivi d’une opération
de construction. Deuxième édition. Ed. Le Moniteur. Nov. 2001
[3] Eric Berrard Missions de L’ingénieur Biomédical dans le cadre de
l’interface entre le bâtiment et les équipements médicaux. Thèse
professionnelle UTC / ENSP – IBMH. Compiègne : Université de
technologie. 2006
[4] Agence Régionale de l’Hospitalisation de Rhône-Alpes. Le SROS
2006 2010. Synthèse des livres I à IV, 2006, Available :
www.parhtage.sante.fr
[5] Ministère de la santé, de la famille et des personnes handicapées.
Direction de l’hospitalisation et de l’organisation des soins. Circulaire
n°DHOS/O/2004/101 du 5 mars 2004 relative à l’élaboration des
SROS de troisième génération. Available : http://www.sante.gouv.fr/
[6] Ministère des affaires sociales, de la santé, et de la ville. Circulaire
n°44 du 10 décembre 1993 relative aux investissements des
établissements de santé publics, Available : http://www.sante.gouv.fr/
[7] Hervé Debaveye – Pierre Haxaire. 160 séquences pour mener une
opération de construction. Collection Méthode. Quatrième édition.
Ed. Le moniteur 2005

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