“Hindsight can be merciless. People of any given era often look back in time and wonder how their predecessors could have been so dimwitted.” James Balog
In these commentaries offering a critique of the approach to the SJHRP, I have tried to not be critical. I may not have succeeded. If I was in the shoes of the decision makers of the time, I’d hope a background in project management, physical planning, and development control would have caused me to take a different approach. But history is replete with cases where crises have reduced one’s professional background to nothing.
Revisiting the Fire
The fire that occurred at St. Jude Hospital (SJH), after midnight on September 8, claimed the lives of two of 47 patients. Moreover, it destroyed the surgical ward on the top floor of the middle wing of the hospital, and inflicted water damage to the ground floor that housed the laboratory, pediatric ward, supplies, and laundry rooms. A covered walkway connecting the outer wings with the middle wing was partly damaged. Other buildings housing the administrative office, stores, cafeteria, A&E, X-Ray, Physiotherapy, Dental, Pharmacy, Medical Records, Outpatient Clinic (incl. Gynecology), Medical and Maternity wards, Obstetrics, were undamaged. Forty-four patients were evacuated, initially to the Vieux fort Comprehensive School Campus B. Later, 13 were transferred to Victoria Hospital (VH) and the remaining 31 were sent home.
The King Administration Approach
Devising an appropriate response to this disaster could not have been easy. Each option would have presented various challenges. For example: should SJH be closed, until it is fully rebuilt and returned to service? Should its operations be moved to a temporary site in Vieux-fort, while reconstruction goes ahead? Eventually, the King Administration decided to: (1) temporarily relocate SJH operations to the George Odlum Stadium, so that the damaged sections of the hospital could be demolished, rebuilt, and equipped and other parts of the facility be renovated; and (2) simultaneously, to build, a 90-bed, state-of-the-art, facility at a new site. Immediate works were scheduled for completion by the end of 2011. With the benefit of 15 years of hindsight, the completion of the rehabilitation works alone would have produced better conditions than that which has existed at the stadium.
The Anthony Administration’s Approach
Elections intervened and in 2011, there was a change in Government. On visiting the project site after the election, PM Kenny Anthony expressed his satisfaction with the overall quality of work done by the King administration, which he assessed as being 55% complete. Later, he announced his Administration’s decision to build a “modern hospital…that would make southerners proud” at an estimated cost of US$125 million. This represented the merger of the simultaneous works announced by the King Administration, into what is now referred to as “Phase 1” of the SJHRP. If all had gone well, this would have been a much more cost-effective approach than what was originally intended. Given the poor physical health of the SJH, this decision was not without merit. The cost was supposed to have been based on an expanded scope of work, “…to ensure compatibility with the critical needs of SJH, and to facilitate improvement in clinical services.” However, it does not appear this estimate was based on detailed drawings and bills of quantities (BOQs); and/or a master plan that addressed the future role of SJH, within the national, secondary healthcare system. He retained the project team that he’d inherited to avoid unnecessary delays, but later dismissed the contractor because of worker compensation issues.
A “build-as-money-becomes-available” approach was adopted, which may have been influenced by challenges associated with the passage of Hurricane Tomas in September 2010, which caused 8 deaths, and damaged social and economic infrastructure, estimated at $336 million. So, money would have been tight. However, for this financing approach to have worked, it would have had to have been supported by a master plan and strategy, that prioritized the buildings to be erected, and that assured functionality within and between them. In August 2014, the Government secured a US$20 million loan from Taiwan to “complete” the project. According to its own calculations, this was $5 million less than what the Government needed. In hindsight, securing full funding via a loan, before starting the project, may have permitted a sounder approach to project management, and eliminated DCA-related issues. Also, it may have enabled a timelier completion of the facility. However, these benefits would not have been realised if detailed plans for the entire facility were not available.
The decision to call elections 6 months before it was Constitutionally due would have near fatal consequences for the SJHRP. When the Anthony Administration left office in June 2016, the SJHRP was reportedly 80% done and would have been fully completed in another 6 months. Collaboration with Accreditation Canada (AC) regarding architectural reviews of the hospital’s layout and final designs, and the preparation of a roadmap, for accreditation of the hospital was reportedly well advanced. AC was slated to visit the project site before a proposed, January 2017 hospital transfer, in anticipation of which nearly $3.5 million worth of equipment was procured and/or ordered. It emerged that while a building was erected on-site, to store this equipment, inexplicably, it was stored in privately-owned warehouses, at additional cost to taxpayers.
The Chastanet Administration’s Approach
On assuming office in 2016, the Chastanet Administration commissioned a technical audit of the project, that identified three options for moving forward: (1) abandonment of phase 1 of facility, inherited from the previous government; (2) continuing work on the facility at an estimated cost of $100 million; and (3) building another facility at a different site. Actually, there were only two options on the table, as abandonment would have required the construction of a new facility. This would have meant ignoring the SIGNIFICANT investment already pumped into the project, by schoolchildren, civil society organizations, taxpayers, and friendly governments. Critically, it also meant extending the plight of SJH patients and staff at the stadium. Perhaps this explains why the author of the technical audit did not dismiss the option of continuing work on the existing facility. He wrote,
“The issues identified are significant; however, we do see a great value present in the works already completed and believe that the project is salvageable and could be converted into a facility that can properly serve the needs of Saint Lucia.”
Initially, the Chastanet Administration seemed set to follow the consultant’s advice and to “make good” the defects that were identified, notably in the emergency building. However, during a visit to the project in October 2017, a group of health officials expressed disappointment that the work done did not meet international standards. Citing the issues and challenges in the Technical Audit –which the consultant noted were not insurmountable– and observations from the site visit by medical officials, the Chastanet Government ceased work on the project and decided to build a 96-bed, Level-4, hospital, over 145,000 square feet of NEW building space, spread over 5 blocks (C, D, E, F, &G). I assume Blocks A&B are those parts of phase 1 of the SJHRP that were supposed to have redesigned and retrofitted “…for functional efficiency and compliance with minimum standards.”
The Chastanet Administration would stretch the limits of wishful thinking, and credulity when it assured the public that the hospital would be completed in 10 months, using a design, finance and build contract. Funding for this phase of the project was obtained through yet another US$30 million loan from Taiwan, which included US$10 million unused from a previous loan. Interestingly, the implementing agency for the project was the Ministry of Economic Development, not the Ministry of Infrastructure, where the requisite technical expertise resides. A similar arrangement was used for the Sir Julian Hunte Highway Project (SJHHP), with well-known, disastrous results.
The Pierre Administration Approach
Yet again, elections would intervene. When the Pierre Administration came into office, it appointed a multidisciplinary team of experts to “review options for the completion and commissioning of the SJH and to advise on the feasibility and requirements for an immediate transfer of operations from the George Odlum Stadium to the original SJH.” This team found that while the structure and external envelope of the three new buildings were between 70-90% complete, the overall project was only 30% complete. Concerns were also raised about the possible harmful, health impacts of the exterior cladding of the building. At that time, EC$ 118 million had already been spent on this second “phase” of the project, commonly called “The Box.” The team identified logistical challenges in completing the top floor of The Box while the ground floor functioned as a hospital. Completion of the bottom floor of the Box was estimated at $72 million, excluding furniture, fittings, and equipment (FFE), while sealing the roof of the Box was estimated to cost $16 million. Consequently, the team concluded that completing phase 1 of the project would be quicker and cheaper than proceeding with The Box.
The full cost of continuing with phase 1 is not yet known. An assumption appears to have been made that it would be lower than completing phase 2 and that an EC$201 million financing agreement with the Saudi Fund in August 2023, would: (1) provide a fully functional, “climate proofed” hospital, that uses renewable energy and water conservation and rainwater harvesting; (2) train staff in the operation and maintenance of bio-medical equipment; and (3) rehabilitate the Stadium. A project steering committee has been established, consisting of representatives of the Government, the SJH, and other relevant stakeholders. A plan is being prepared to guide the transition of the hospital from the Stadium to the Augier site.
What Went Wrong?
Not many things went right. An aerial view of the complex offers a disheartening picture of the sum of what went wrong. We now have a hospital complex with a humongous footprint that far exceeds what was originally intended and that raises many financial and operational viability concerns. The bottom line is that by the time SJH is commissioned, it will likely cost our country about EC$450 million—at least twice as much as the OKEU. For some time in the future, it will have surplus space, but it may not have adequate human capacity.
Development Control Missteps
The Physical Planning and Development Act binds the Government because it carries out building, engineering, and other operations in, on, over or under land. If the approach to the SJHRP had been in keeping with planning law from the outset, this commentary would not have been necessary. While DCA approval would not have been required for basic renovation works, that retained the footprint of the old buildings, the reconstruction of the damaged buildings would automatically have required DCA approval, given their public use. Recalling the fire, approval of the mechanical, electrical, and plumbing (MEP) plans would have been critical. Granted, there were challenges involved with preparing “as-built” drawings for those old parts of the SJH being retained. The merger of old and new buildings would not have helped. However, the preparation of detailed drawings for submission to the DCA would have enabled the preparation of detailed costings. DCA approval for 4 of the buildings on the project–laundry, dialysis, physiotherapy, and maintenance–was not obtained until 2019.
Perhaps the most consequential error was not entrusting the design of the facility to an architect or firm experienced in hospital design, from the “get-go,” as was done with the OK-EU. Given the vast amount of money spent on the OK-EU design, using a scaled-down version of it for a new SJH would have shaved off loads of time and money from the project. If these options were considered, it appears they were dismissed, as the Chastanet Administration decided to copy the design of a general hospital in the Cayman Islands. Hopefully, this design pays homage to the key principles of hospital design, which include prioritizing functionality over architectural appeal, by accommodating, bulky equipment and positioning operation theatres, emergency rooms, ICUs, and radiology services in proximity. Research by the British Medical Association has shown that good hospital design can produce several benefits. Patient recovery time can be reduced if there is adequate exposure to daylight. Exposure to nature and gardens can help to reduce depression, improve patients’ moods, and reduce blood pressure and stress levels. Open windows in patient rooms can improve airflow and reduce microbial diversity and long corridors can reduce nurses’ fatigue and stress.
Lessons
Key lessons from the approach to the SJRP can be summarized as follows:
- To promote timely completion of large complex projects, adequate funding should be assured from the outset, based on site plans, detailed drawing and bills of quantities.
- Obtaining the requisite planning approvals in a timely manner can contribute to safe use of a building and avoid delays. Effective project management must be prioritized for every public sector project.
- Continuity of sound governance from one administration to another can positively contribute to on-time and within-budget completion of projects.
- The use of competent and committed consultants and stakeholder monitoring mechanisms to oversee the execution of public sector projects can yield immeasurable benefits.
Conclusion
We must hope there’s no repeat of this calamitous St. Jude Hospital Reconstruction Project (SJHRP). However, our seeming reluctance to put aside political allegiances and extract and absorb the many varied lessons from the project, suggests another, similar calamity is on the cards.