Sustainable Cities and Society 30 (2017) 217–222

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Sustainable Cities and Society

journal homepage: www.elsevier.com/locate/scs

Quantitative analysis of the impact of maintenance management on

the energy consumption of a hospital in Extremadura (Spain)
J. García-Sanz-Calcedo a,∗ , M. Gómez-Chaparro b
a
School of Industrial Engineering, Department of Graphical Expression and Projects, University of Extremadura, 06007 Badajoz, Spain
b
HM Hospitals, Maintenance Engineer, 28015 Madrid, Spain

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this paper is to analyse the impact of maintenance management on the energy consumption
Received 19 November 2016 of a hospital in Extremadura (Spain) and to look for existing relationships between the time spent on
Received in revised form 24 January 2017 maintenance operations and the energy consumption of the building.
Accepted 25 January 2017
The results show that an average annual increase of 6% in time spent on preventive maintenance
Available online 9 February 2017
operations, over a period of 5 years, resulted in a 20% decrease in the demand for corrective maintenance
and an average annual saving of 500 MWh in energy consumption. This in turn prevented the release of
Keywords:
186 tons of CO2 and other greenhouse gases into the atmosphere. This represents an annual saving of
Hospital maintenance
Healthcare engineering
75,000 D , with no increase in either human resources used nor in maintenance costs. Air conditioning
Facilities management installations, Low Voltage systems and Plumbing installations consume more than 80% of the resources
applied to building maintenance.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction construction and on efficient maintenance, in this case referring

Maintenance has become increasingly important in recent
decades, mainly due to the increased sophistication of building
facilities and to the importance of maintaining their conditions of
use (Horner, El-Haram, & Munns, 1997).
In hospitals and health centres, maintenance is one of the most
critical activities, as the safety of users and workers depends on
proper administration (Geisler, 2002).
According to the findings of the Building Laboratory of the Uni-
versity of Barcelona (Garcia-Sanz-Calcedo, 2014), analysis of the
operating costs of a building during its lifetime showed that 5%
of the cost corresponds to the project, 20% to construction, 65% to
maintenance and running costs and the remaining 10% corresponds
to the cost of renovations or demolition. However, in a healthcare
centre, operating costs are higher, mainly due to the high intensity
of its use (Loustaunau & Beguería, 1992).
Hospitals are equipped with complex and expensive facilities
and equipment, the correct usage of which conditions the qual-
ity of the services provided (Mohamad & Bin, 2009). The state and
regularity of use of these resources depends fundamentally on ade-
quate design of the facilities and equipment, on the quality of the
∗ Corresponding author.
E-mail addresses: jgsanz@unex.es (J. García-Sanz-Calcedo),
mgomezchaparro@hotmail.com (M. Gómez-Chaparro).
to the combination of human and material resources, needed to
ensure the proper operation of the building’s assets (Ministerio de
Sanidad y Consumo de España, 1990).
Hospital engineering now plays a decisive role in the manage-
ment of a hospital and one of its objectives is focused on the energy
and environmental efficiency of the building (Chyu, Austin, Calisir,
& Sanz-Calcedo, 2015) as well as on maintaining the Environmental
Biosafety (BSA) conditions of the said building, from the perspec-
tive of patient safety (Arrechea Enériz, Aldea Jimeno, González
Gutiérrez, Jimeno Llerena y, & Peñalva Segura, 2011).
From the point of view of cost management, it is important
to note that maintenance costs are not only those that produce
an economic cost; other elements need to be taken into con-
sideration such as the costs of shutdown, energy consumption,
atmospheric emissions and aging of the equipment and facilities
as a result of operating in degraded conditions (Kaplan & Norton,
2004; Akintoye, 2005).
Facility managers play an important role in predicting the condi-
tion of the facilities based on their experience, their different values,
beliefs, perceptions and expectations. The problem is that most of
the facility managers do not participate in the briefing, design and
cost analysis of the new building at development stage (Shohet &
Nobili, 2015). As health facilities tend to operate 24 h a day, perfor-
mance of the facilities is critical. The healthcare industry is a public
sector which cannot afford “trial and error” approaches or service

http://dx.doi.org/10.1016/j.scs.2017.01.019
2210-6707/© 2017 Elsevier Ltd. All rights reserved.
218 J. García-Sanz-Calcedo, M. Gómez-Chaparro / Sustainable Cities and Society 30 (2017) 217–222

Fig. 1. Trends of preventive and corrective maintenance by year.

Table 1
Average time dedicated to preventive maintenance in the period 2010–2015, according to the type of installation.

Installation Code Time of preventive maintenance (h) %

Domestic Hot Water DHW 322 3,68%

Compressed Air CA 28 0,32%
Low Voltage LV 2.183 24,96%
Air- Comditioning AC 3.647 41,70%
Communications COM 19 0,21%
Const. and civil engineering CCE 404 4,62%
Plumbing PB 1.014 11,60%
Industrial cooling IC 246 2,82%
Other OT 464 5,49%
Fire Safety FS 208 2,38%
Liquid Petroleum Fuels LPF 20 0,23%
Sanitation SAN 130 1,48%
Medical Use MED 45 0,51%

failure as any mistake could result in the loss of life of a patient.
(Mwanza & Mbohwa, 2015).
Abd Rani, Baharum, Nizam Akbar, and Nawawi (2015) analysed
the perception of maintenance management in Healthcare Facili-
ties (Abd Rani et al., 2015). They provide an overview of the types of
maintenance strategy applied to maintain facilities while still sat-
isfying the end user. The results show that there is a relationship
between the type of maintenance strategy implemented and end
user satisfaction.
Shohet, Lavy-Leibovich, and Bar-On (2003) studied the impact
of maintenance within a hospital (Shohet, 2003). The survey results
show that the overall state of the facilities is one of deterioration.
One building system, namely the communication and low voltage
system, was consistently found to be in poor condition and four sys-
tems (exterior envelope, interior finishing, water and waste-water,
and HVAC) were in a state of deterioration (Shohet & Lavy, 2004).
Al-Zubaidim & Christer (1997) developed a building mainte-
nance manpower simulation model within the case context of a
specific hospital complex to investigate the potential gain to be
achieved by using different manpower, management and opera-
tional procedures (Al-Zubaidim & Christer, 1997).
Al-Momani, Al-Tahat, and Jaradat (2006) studied the perfor-
mance measures for the improvement of maintenance effective-
ness. The results showed that despite a general increase in the
availability of equipment, there is still a considerable average repair
time of the equipment from the registered failure day. This varies
according to the type of equipment and its complexity (Al-Momani
et al., 2006).
Maintenance costs throughout the working life of a facility are
very important when choosing the appropriate HVAC system to
be installed in healthcare buildings (Al-Turki, 2011). The central
equipment shows lower maintenance costs than partial systems
(ARI, 2015).
According to ATECYR (2001), maintenance costs represent
between 2% and 10% of the original investment in equipment,
depending on the complexity of the system (ATECYR, 2001).
In recent years, various guides have been published which pro-
pose techniques to improve maintenance management (Ruiz Moya,
2010; ATECYR, 2012; Garcia Sanz-Calcedo, 2014), but these do not
quantify the potential energy saving that would come from proper
management.
The aim of this paper is to perform a quantitative analysis of the
impact of maintenance management on the energy consumption of
a hospital in Extremadura (Spain) and to analyse the relationship
between the time spent on maintenance, energy consumption and
healthcare activity.
2. Methodology
The hospital chosen for analysis is located in a town in the
province of Badajoz, in south-western Spain. It has 75 beds, a floor
area of 12,894 m2 and a usable space of 8507 m2 . The hospital
was designed and planned in 2003, constructed between 2004 and
2006 and became operational in April 2007, intending to serve a
population of 35,000 inhabitants spread over a wide geographical
area.
The hospital has a total of 175 workers including staff from
external companies that deal with security and maintenance and it
provides major outpatient surgery for interventions in the areas of
General Surgery, Urology, Gynaecology and Traumatology. In the
outpatient area, services offered include Neurology, Pulmonology,
Internal Medicine, General Surgery, Anaesthesia, Ophthalmology,
 J. García-Sanz-Calcedo, M. Gómez-Chaparro / Sustainable Cities and Society 30 (2017) 217–222 219

Fig. 2. Average time invested in preventive maintenance operations in the period 2010–2015 according to the type of installation.

Fig. 3. Annual trend for the consumption of water between 2008 and 2015.

Orthopaedics, Urology, Otorhinolaryngology, Radiology and Cardi-
ology tests (Plan de Salud de Extremadura, 2012).
The time invested in maintenance operations and the
number of job reports used to develop the maintenance
tasks within the period 2010–2015 were analysed. To obtain
this information, IT databases of maintenance management
programmes were used, aided by PRISMANET and PRISMA
II (http://www.prismasoftwaregestion.com/, 2017) computers,
installed in the hospital.
The monthly consumption of water and electricity between
2008 and 2015 was analysed using data provided by the supplier
companies which was then compared with existing data in hospital
records. Information related to the volume of diesel C fuel used for
both heating and domestic hot water (DHW), consumed annually
in the hospital, was collected. The lower calorific power (LCP) of
diesel C is taken to have a value of 10,28 kWh/l (IDAE, 2010). Eq.
(1) was used to calculate the energy consumption:
E T = V G ∗ 10, 28 + E E
where ET is the total annual energy consumption in the hospital
expressed in kWh, EE is the annual electrical energy consumed
under normal operating conditions in the hospital expressed in
kWh and VG is the annual volume of diesel C expressed in litres.
Operating costs were obtained from the software application
system used by the Finance Department of the hospital and include
the cost of legally mandatory periodic inspections on low voltage
installations, the transformation centre, oil installations, pressure
equipment and fire detection and control installations. Elements
not included are electro medical equipment and lifting devices
which, in this case study, are managed by legally accredited exter-
nal companies. Maintenance operations were carried out by 9
employees, working in shifts over a 24 h a day period, 365 days
a year. The maintenance service took responsibility for the costs of
materials needed for equipment and installations costing less than
50 D . The average annual cost of providing the maintenance service
was 335,417 D per year in the period analysed and the activity car-
ried out in the hospital maintenance service is classified into two
(1) types: corrective and preventive.
220 J. García-Sanz-Calcedo, M. Gómez-Chaparro / Sustainable Cities and Society 30 (2017) 217–222

Fig. 4. Annual trend for energy consumption between 2008 and 2015.

Fig. 5. The relationship between annual water consumption and the time spent on preventive maintenance in the period 2010–2015.

3. Results Fig. 2 shows the average time spent on preventive maintenance

Below are the results obtained from the study tasks.
3.1. Annual time dedicated to preventive and corrective
maintenance operations
Fig. 1 represents the number of annual maintenance hours
between 2010 and 2015, distinguishing between preventive and
corrective maintenance tasks.
In Fig. 1, we see that most of the operational maintenance time
of the hospital is dedicated to tasks involving preventive mainte-
nance, especially in recent years. Specifically, in 2015, corrective
maintenance accounted for 16% of the total of maintenance hours
while in 2010 it accounted for 36%. It is further noted that the total
number of maintenance hours increased in the last four years, from
9071 h to 11,973 h (+32%).
Table 1 shows the average time values and percentages devoted
to preventive maintenance between 2010 and 2015, according to
the type of installation.
between 2010 and 2015 according to the type of hospital installa-
tion.
Air conditioning systems, low voltage systems and plumbing
were found to account for 80% of the workload, the remaining
20% being divided among the remaining different installa-
tions.
3.2. Annual consumption of cold water for human consumption
(CWHC)
Fig. 3 shows the trend regarding annual consumption of cold
water for human consumption (CWHC), between 2007 and 2015,
in the hospital studied.
The curve shows an increasing trend in annual water consump-
tion associated with the increase in healthcare activity provided by
the hospital. However, it has been found that this consumption is
lower than usual in such buildings (González, García-Sanz-Calcedo,
Salgado, & Mena, 2016).
 J. García-Sanz-Calcedo, M. Gómez-Chaparro / Sustainable Cities and Society 30 (2017) 217–222 221

Table 2
indicators related to hospital maintenance.

Índex unit preventive corrective total

Annual time per MWh of energy consumed h year/MWh 1.50 0.56 2.06
Annual interventions per MWh of energy No./MWh 2.07 0.31 2.38
Annual time per m3 of water consumed h year/m3 1.10 0.42 1.52
Annual interventions per m3 of water No./m3 1.53 0.23 1.76
Annual time per m2 of construction h year/m2 0.57 0.21 0.78
Annual interventions per m2 of construction No./m2 0.78 0.12 0.90
Annual time per m2 of usable space h year/m2 0.71 0.26 0.97
Annual interventions time per m2 of usable space No./m2 0.98 0.15 1.12
Annual maintenance cost per hour D /h 45.93 122.04 167.97
Cost per annual maintenance intervention D /h 33.17 219.38 252.55
Annual maintenance time per bed h/bed 107.40 40.42 147,81
Annual maintenance intervention per bed No./bed 148.69 22.49 171.17
Cost of maintenance over investment % 0.73 1.94 2.67
Maintenance time in possible hours in a year – 0.83 0.31 1.14
Maintenance interventions in possible hours in a year – 1.15 0.17 1.32

Fig. 6. The relationship between annual energy consumption and time spent on
preventive maintenance. Fig. 7. The relationship between energy consumption and time spent on the pre-
ventive maintenance of air-conditioning, CWHC and low voltage systems.

3.3. Annual energy consumption

Fig. 4 shows the annual energy consumption expressed in MWh
between 2007 and 2015, distinguishing between the consumption
of diesel fuel for heating and that for electricity.
A downward trend is observed in the case of diesel C and from
2009 in the case of electricity. In 2015, consumption was 1296 MWh
less than in 2008.
energy consumption of the maintenance performed on each type
of installation was analysed, as shown in Fig. 7.
As can be seen in Fig. 7, the relationship detected in Fig. 6 is due
mainly to the hours of preventive maintenance on air-conditioning,
domestic hot water and low voltage systems which, as we showed
earlier, are the systems which consume most annual maintenance
time.

3.4. The relationship between operation times of preventive and
corrective maintenance
Fig. 5 shows the existing relationship between time spent annu-
ally in preventive and corrective maintenance operations in the
period 2010–2015.
It can be seen that the increase in hours of preventive mainte-
nance has led to a lesser demand for corrective maintenance.
3.5. Relationship between annual energy consumption and time
spent on maintenance operations
To confirm whether there is indeed a relationship between
energy consumption and time spent on maintenance operations,
Fig. 6 shows the existing relationship between annual time spent
on preventive maintenance and the annual energy consumption of
the hospital between 2010 and 2015.
Using Fig. 6 we can deduce that there is a direct relationship
between annual energy consumption and annual preventive main-
tenance time. In order to elaborate further on this, the influence on
3.6. Indicators related to maintenance
In Table 2, some indicators detected in the job reports are shown.
4. Discussion
The fact that each year a higher percentage of hours are dedi-
cated to preventive maintenance indicates that the hospital is being
maintained properly and that hospital facilities are under control.
That is to say, it is related to the state of conservation of the build-
ing, because if maintenance had been neglected in previous years,
it would surely be necessary to invest an extra amount of time and
money in order to obtain these results (Gallagher, 1998).
Regarding the decrease in the amount of energy consumed,
it is clear that adequate design in the planning stage is of vital
importance. During the period that was analysed, it was found that
continually learning how to make better use of the facilities by the
end user and maintenance personnel led to a significant amount of
adjustments to minimize the amount of energy resources needed.
Such adjustments may have influenced the fact that the obtained
222 J. García-Sanz-Calcedo, M. Gómez-Chaparro / Sustainable Cities and Society 30 (2017) 217–222
results were particularly satisfactory. However, this learning factor
alone justifies the initial operational years of the building.
Because the air-conditioning, Low Voltage and Plumbing instal-
lations consume more than 80% of the resources applied to building
maintenance and final energy consumption, more attention should
be paid to these installations in order to minimize shutdown.
Reliability Centred Maintenance should be used in order to
achieve a good rate of equipment availability. The decision model
proposed takes into account the different types of equipment cat-
egorized as either critical or ordinary equipment. Management
commitment to the proposed model will facilitate the achievement
of high equipment availability. Additional maintenance personnel
and training on new trends in maintenance is important for the
success of the proposed RCM model. Implementing this model will
improve the service delivery of the three hospitals if the follow-
ing recommendations are taken into consideration by the hospitals
(Shohet et al., 2003).
It is advisable to perform periodic maintenance audits in order
to determine whether the management of the actions carried out
in the building is adequate and to anticipate the trend for demand
for maintenance in the future (López Murillo, 2011).
The findings and conclusions of this study can be compared to
other hospitals with similar facilities and equipment.
5. Conclusions
The results show that an average annual increase of 6% in time
spent on preventive maintenance operations, over a period of 5
years, resulted in a 20% decrease in the demand for corrective
maintenance and an average annual saving of 500 MWh in energy
consumption. This in turn prevented the release of 186 tons of
CO2 and other greenhouse gases into the atmosphere and gave an
average saving of 75,000 D /year, without additional costs or extra
investment.
In addition, the decrease in unscheduled shutdowns in the
equipment has meant an increase in the availability of the installa-
tions, thus increasing the quality perceived by the user.
Furthermore, increased time spent on preventive maintenance
has two positive effects. The first is that the demand for correc-
tive maintenance is less each year. The second is the elimination
of unnecessary energy consumption. As a consequence, significant
savings in hospital energy bills have been obtained without increas-
ing maintenance costs.
Acknowledgements
This study has been carried out through the Research Projects
GR-15057 linked to the IV Regional Plan of Research and Investiga-
tion from the General Government of Extremadura 2015–2017.
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