Medical Gas Systems Maintainability Risks in Healthcare Facilities: A Design Optimization Approach

Abstract

Medical gas pipeline systems (MGPSs) are crucial for operating healthcare facilities as life-saving systems. The sustainability of MGPSs mandates optimum performance by reducing maintenance and repairs. Since faulty design is inventible, healthcare facilities endure several design-caused maintenance issues that endanger the sustainability of healthcare services and maintenance life cycle costs. These design decisions could have been avoided if proper consideration for maintenance had been applied. Eleven experts participated in semi-structured interviews guided by Staticized Group Techniques to identify and evaluate the maintenance issues. The results included identifying 52 design-related maintenance issues that pose maintainability risks. The findings primarily fall under emergency gas supply availability, future expansion readiness, and accessibility of maintenance. The most critical issue found is the excessive cutting-outs of the pipelines when upgrading the system. For new healthcare facilities, the results of this research provide practical help for designers to avoid MGPS issues. A scarcity of benchmark research and geographical factors are some limitations to this study.

1. Introduction

Healthcare facilities must operate all the time for all days of the week. This perpetual nature requires an ensured supply of life-saving systems. Medical gas pipeline systems (MGPSs) are major life-saving systems in healthcare facilities [1,2]. An MGPS is used to transport a variety of often combustible medical gases, including oxygen, medical air, and anesthesia to support healthcare services. For instance, the nitrous oxide gas (N₂O) used for anesthesia is delivered via bulk tanks, pipelines, and control valves. The commonly used medical gases in healthcare facilities are oxygen (O₂), medical air, carbon dioxide (CO₂), and nitrous oxide (N₂O) [3]. Poor design contributes to the occurrence of errors in anesthesia practice, which is catastrophic [4,5]. Unfortunately, design errors may occur in an MGPS, which can be hidden even after construction [6]. Although precautionary measures are advised, death by accident by cross-connecting gasses continues to occur, and this requires a failsafe design methodology [7,8]. A certain study has urged healthcare facilities to optimize the management of MGPSs for capital savings and environmental reasons [3]. Therefore, MGPS’s design maintainability has a role to play in the overall sustainability of healthcare services, which is emphasized by the design decisions made in the earlier stages.

In the wake of the COVID-19 pandemic, healthcare facilities have faced new challenges to improve their future experience with such viruses. Many issues that have resulted from COVID-19 are related to facility design itself. Shortage of space to handle the patient surge, infection spread, and limitation of hospital beds are some of the problematic issues that require a shift in the design, construction, and maintenance of healthcare facilities [9]. When a pandemic like COVID-19 breaks out, there will be a great need for intensive care unit (ICU) beds and ventilators. Such high demand may not be fully accommodated, and alternative means on the part of the healthcare facility would be required to provide respiratory support and ventilation to infected patients. In Garg and Dewan’s (2022) [9] research on the post-COVID-19 landcape, they suggested some changes to the design of new hospitals. Their plan calls for re-thinking the design layout of the various departments that MGPS routine design criteria will change.

Faulty design is the reason for maintenance costs [10]. Hence, maintenance impacts can be avoided if the design stage considers maintainability, including costs and health services continuity. While this seems evident, few owners of new projects consider this a priority issue [11,12]. Even though many factors in the design stages are considered, such as cost and performance, maintainability is underrated [13,14,15]. The maintainability of facilities is defined by the overall design decisions and selections that may address maintenance issues or overlook them [11]. If a maintenance concern is addressed sufficiently, the maintainability improves and eventually saves future maintenance costs that result in a lower life cycle cost.

In the construction industry, design issues such as poor design, errors, or omissions are inevitable [16,17], and healthcare facilities frequently witness design issues [18]. Healthcare facility design comprises complex iterative processes [19]. Although engineering codes and quality manuals exist, design errors continue to occur [20,21,22]. In many instances, the literature uses building defects, design defects, and design errors interchangeably [23]. Design errors have been found to contribute as much as 30% to a project’s cost, and they can lead to failures, accidents, and loss of life in facilities [24]. Unfortunately, engineering designers face challenges in learning from reoccurring design errors which result in death, injuries, and cost overruns [21,25]. In addition to best practices, healthcare facility designers depend on their experience and local knowledge about clients’ requirements [26]. For example, pipelines’ cross-connections, loss of pressure, and cylinder pin indexing confusion are all continuous issues that cause deaths in healthcare facilities due to design and installation errors [27]. Furthermore, operational errors, such as deaths, can result from staff mistakes in recognizing plate labeling, and color-coding systems adds extra safety measures for future design [27,28,29]. These measures employ early prevention at the design stage.

Mechanical, electrical, and plumbing (MEP) systems, which include MGPSs, are more susceptible to problems than other building divisions, and contribute 46% of total potential change orders [30]. The difficulty with an MGPS is the sparse knowledge of designers and installers about operating this system [31]. Moreover, there is a challenge in finding reliable data about the average consumption of medical gases [3]. This challenge prevents designers from fully comprehending the impact of their design based on historical experience, and calls for better communication with facility managements to obtain data.

Designers’ lack of communication with facility managers is a cause for recurring design defects [18,20,32,33]. Therefore, feedback from facility managers about design-caused maintenance issues can provide an approach to achieving better maintainability. Healthcare facility design that considers maintainability includes design alternatives to reduce maintenance costs along the facility life cycle. Thus, the establishment of such a feedback cycle is essential to provide real-life experiences of maintenance issues to the eyes of designers. If this process is successful, overall life cycle cost savings can be achieved, as well as an improved operational continuity for the healthcare services.

This study aims to improve the maintainability of MGPSs by utilizing the experience of healthcare facility management and maintenance professionals who possess MGPS-related expertise. The more maintainable an MGPS can be, the more sustainable are healthcare facilities. This aim was approached by achieving two objectives. The first was identifying a list of MGPS design-caused maintenance issues, whereas the second was evaluating those design decisions. Achieving the objectives will provide a helpful tool for designers to avoid maintenance-unfriendly decisions.

2. Literature Review

Some studies addressed several building service systems in an attempt to improve the maintainability of buildings [14,34,35,36,37]. In contrast, several studies focused on a particular building system for other types of facilities [33,38,39,40,41]. However, these studies have not investigated MGPSs’ maintainability.

Although some studies have investigated the maintainability of healthcare facilities, almost none of these studies have considered the maintainability of MGPSs. In Jaafar and Othman (2016) [42], the maintainability of healthcare facilities is addressed regarding accessibility, selection of materials, and environment. The latter study has not included any MEP systems. Another study on healthcare facility maintainability focused on elevators only, and provided a list of maintenance issues and a proposed ranking [43]. Marzouk and Hanafy (2022) [44] proposed a collaborative framework utilizing building information modelling (BIM) for a maintainability data exchange, a design maintainability assessment, and business intelligence (BI) integration; however, it did not include MGPS-specific design defects or maintenance issues.

Previous research on MGPSs have investigated the risks that may arise from the operation and maintenance of healthcare facilities. Anesthetic practitioners, clinical engineers, and safety practitioners reported several cases of deaths and injuries, fires, and near-misses that originate from the use of MGPSs [7,27,29,45,46]. While design-caused maintenance issues need further studies, it has been established that design errors lead to cost and performance impacts [10,12,32,33,41,47]. Therefore, it is prudent to eliminate any possibility of latent design errors that may lead to unfavorable events in the future. In addition to errors in design decisions and selections, alteration to designs while in the design stage or early construction is considered to be among the construction changes which are inevitable [48,49,50]. Such rectifications require unfavorable alterations to the maintenance operations.

Some studies provide references for the cost burden of inaccurate design decisions. A healthcare facility case study revealed that two-thirds of its contingency budget was spent on rectifying design errors during construction [51]. This study affirms that design errors continue to occur in hospitals, and these errors may lead to failures and cost, as well as environmental and social impacts. While this study proposed strategies to prevent design errors, it has not researched the facility management feedback aspect to improve design. Other studies also investigated design errors, but they focused on the human, technical, and contextual aspects that lead to engendering errors, without delving into maintenance or learning from facility management [17,21,24,25,49,52]. However, few studies have tried to formulate feedback resulting from design errors [53,54,55], and these studies provide insufficient reference to the utilization of the facility management experts’ knowledge.

To compare maintainability with other design improvement approaches, the authors have found evidence-based design (EBD) as one methodology used in healthcare facilities to improve design output. Several studies have promoted this direction [19,56,57]. A definition of EBD is the utilization of the best data available from research at the instance of making decisions, which eventually results in proven enhancements of healthcare facilities in regard to their “clinical outcomes, economic performance, productivity, customer satisfaction, and cultural measures” [58]. Most of the research on EBD concepts revolves around the care of future patients in facilities and their therapeutic experience. Nevertheless, EBD studies have not focused on maintenance considerations and learning from the recurring mistakes. Some other studies focused on a similar approach called patient-centered design [59,60,61].

3. Research Methodology

3.1. Staticized Group Techniques (SGT)

Obtaining experts’ judgments is a limited but growing trend in construction engineering and management research, which includes Staticized Group Techniques (SGT) and the Delphi method [62,63]. These two methodologies are similar in their purpose of gathering information from experts, but they differ in the re-iterated feedback rounds encouraged by the Delphi method. Targeting consensus by multiple rounds may push the participants to regress around the mean [64,65]. Some studies which compared SGT to the Delphi method asserted the accuracy of Delphi [66]; however, difficulty and time duration affect the participation level in surveys [67,68]. Besides, traditional tools such as surveys and interviews may not be practical when a specialized topic is investigated [63,69]. Unless consensus is mandatory, SGT provides a suitable tool to reflect on experts’ opinions [69]. The authors adopted SGT as a framework to elicit experts’ knowledge about MGPS maintenance issues and evaluations. In essence, this approach relates to previous maintainability studies that conveniently sampled experts to provide their expertise [32,33,43,70,71]. In a similar manner, this research employed an SGT-based approach to elicit knowledge from experts selected based on pre-determined qualifications.

3.2. Study Participants

To selects experts for this research, the author contemplated either selecting many participants, which would have impeded close interaction and presented administration difficulties; alternatively, a small number of participants could be selected, which allowed close interaction and commitment [67]. In general, there is a dearth of specialized professionals in MGPS maintenance in Saudi Arabia, where this study is conducted. Therefore, reaching out to experts was a challenge, which necessitated the latter selection. Some studies indicated that panels usually contain 8 to 16 panelists [69], and several SGT studies included 8 to 9 panelists [72,73,74,75]. To this end, the authors ensured that the number of experts was between 8 and 16 qualified experts. In Figure 1 is shown the steps of the research methodology; the following steps listed explain in more detail the methodology followed.

• The authors reviewed the state-of-the-art literature about MGPS maintainability and design-caused maintenance issues. The results were grouped by the components that comprise the MGPS as indicated by Frank (2020) [45].
• Semi-structured interviews with experts in MGPSs were conducted. Eleven experts were named to be the panel that critiqued the outcome of Step 1. The selection of experts was based on their qualifications, which were defined by their years of experience and academic background (

  Table 1. The experts’ panel qualifications prerequisites.

  Qualification	Minimum Level	Notes
  Education	Bachelor’s degree
  Major	Mechanical, electrical, or electromechanics
  Experience	15 years	Prior healthcare facility management
  Role	Owner, consultant, or contractor	Either role should include the part that exposed experts to MGPS maintenance
  Location	Saudi Arabia	To create conformity of the knowledge, experts were selected from a specific geographical location

  ). To qualify as an expert who could provide judgments, the years of experience in MGPSs specifically should have been more than 15 years [76]. In some cases, 10 years of MGPS experience was accepted if prior experience in MEP systems existed for at least 5 years. However, the authors ensured the selected experts were referred to as such by the industry to affirm their credibility since there were no professional bodies to draw from to address experts in this field. In our results, 52 maintenance issues were determined to be among the recurring issues that are encountered by facility managers and MGPS maintenance professionals. In

  Table 2. Maintenance issues in MGPSs.

  System Component	SN	Maintenance Issue	System Component	SN	Maintenance Issue
  Area Alarms/AVSU	1	Fire cases response late		2	Inaccessibility to the panel
  Bulk Systems	3	Gas leaks/Fire risk		4	Pandemic quick response failure
  	5	Alternate tanks’ unavailability		6	Dirt or debris
  	7	Water ponds		8	Poor access for maintenance
  	9	Poor lighting		10	Corrosion of metal parts
  Manifolds Room	11	Fire risk		12	Copper pipes damage
  	13	Dirt or debris		14	Noise from maintenance
  	15	Pandemic quick response failure		16	Excessive heat/improper ventilation
  Master Alarms	17	Delayed response to pressure drop		18	Delayed response to humidity increase
  	19	Delayed response to electricity outage	Medical Air Treatment Systems	20	Failure to provide alternative
  	21	Dirt and dusts		22	Noise
  	23	System underperformance		24	Pandemic quick response failure
  	25	Oil contamination		26	Poor airflow
  	27	Poor access for maintenance	Outlets and Inlets (terminal units)	28	Gas leaks
  	29	Inconsistent inlets and outlets		30	Pandemic quick response failure
  	31	Future expansion challenges	Piping Network	32	Multiple cutting-outs when upgrading
  	33	Electricity shorts		34	Intersections with cable routes
  	35	Pressure drop		36	Mixing gases by pipes’ cross-connection
  	37	Pandemic quick response failure		38	Damage to other systems when performing maintenance
  	39	Difficulties in carrying out maintenance		40	Increased challenges to change or upgrade the system
  	41	Poor airflow	Vacuum Pumps	42	Poor vacuum
  	43	Clogs		44	Dirty and dusty area
  	45	Machine damage		46	Faulty control panel
  Valves	47	Maintenance shutdowns require major operation suspension		48	Fire risk
  	49	Noise		50	Infection/Contamination
  	51	Pandemic quick response failure		52	Damage to other systems when performing maintenance

  and Appendix A are compiled maintenance issues and their possible causes. All experts were asked to consider the impact of each issue in terms of health and contamination, disruption costs, and maintenance costs. To avoid bias, the authors took the role of a moderator, which involved discussions with participants about their input. Opting out due to haphazard selection was carefully monitored.
• Each expert on the panel was asked to evaluate each design-caused maintenance issue based on its impact and probability of occurrence based on a 5-point Likert scale. This instrument employed a different scale for each of the probabilities and impacts. The 5-point Likert scale of the probability was based on the occurrence of issues. It measured 5 as “Always” when an occurrence happens more than once a month, 4 as “Frequently” when an occurrence happens once per 3 months, 3 as “Sometimes” when an occurrence happens once a year, 2 as “Scarcely” when an occurrence happens once each 5 years, and 1 as “Never” when an occurrence happens once or less each 10 years. The impact scale measure 5 as “Catastrophic”, 4 as “Major”, 3 as “Moderate”, 2 as “Minor”, and 1 as “Insignificant”.
• Consequently, the survey results were analyzed statistically. The analysis of descriptive statistics was conducted to measure the central tendency and variability of the results.
• The risk value (RI) was calculated for each maintenance issue. All experts evaluated probability and impact, and the multiplication of them yielded the RI. Further, the relative importance index (RII) was measured to determine the relative importance of the identified probability and impact individually. Although a weighted mean was provided, the use of the RII was selected because it was easy for participants to comprehend and justify the implications of rating probabilities and impacts separately; additionally, the number of issues investigated makes it effective to use RII [77].
• The reliability of the questionnaire was tested to measure the internal consistency based on Cronbach’s alpha. Cronbach’s alpha inspects the Likert-type scales to ensure internal consistency and reliability, and it must be close to 1.0 [78].

$$\mathsf{\alpha }=(\mathrm{k}÷(\mathrm{k}-1\left)\right)\times (1-(\left({{\displaystyle \sum }}_{\mathrm{i}=1}^{\mathrm{k}}{\mathsf{\sigma }}_{\mathrm{i}}^2\right)÷{\mathsf{\sigma }}_{\mathrm{X}}^2\left)\right))$$

(1)

where k is the number of test items, ${\mathsf{\sigma }}_{\mathrm{i}}^2$ i is the variance of a single test item X_i, and ${\mathsf{\sigma }}_{\mathrm{X}}^2$ is the variance of the overall test items X.

In this research, design decisions that result in maintenance issues were considered maintainability risks in a similar way to some previous maintainability studies [34,36,79,80,81]. Some of these studies incorporated experts’ knowledge in the risk evaluation of the maintainability issues [36]. The risk analysis perceived by construction professionals mostly has been translated into the evaluation of probability and the impacts of events based on experts’ intuitions and judgements [82,83]. Hence, the risk value (RI) was provided by the multiplication of the probability of an occurrence of a risk event and the impact [83,84,85].

RI = P × I

(2)

where RI is risk value, P is the probability, and I is the impact.

4. Results

Out of many targeted, 11 experts participated in semi-structured interviews in which their perspectives on MGPS maintenance were discussed thoroughly. Not only did they provide critique regarding the MGPS maintenance issues proposed by authors, but they also added more issues and provided insight into the causes which helped in piloting the questionnaire. It was discovered that there could be various explanations for a certain maintenance issue from several experts. However, the design causation concept was maintained. Further, the evaluation of probability and impact were discussed carefully by the authors, who enforced a moderator role to cultivate proper data. Participants used a scale of 1–5 to evaluate each issue.

In

Table 3. The statistical analysis of MGPS maintenance defect risks.

System Component	Maintenance Issue	Probability			Impact		RI		Ranking
		RII	Weighted Mean	SD	RII	Weighted Mean	SD
Area Alarms/AVSU	1	56.4%	2.82	3.411	65.5%	3.27	3.490	9.22	18
	2	54.5%	2.73	3.191	67.3%	3.36	4.068	9.17	19
Bulk Systems	3	36.4%	1.82	1.907	78.2%	3.91	3.593	7.11	39
	4	38.2%	1.91	3.593	74.5%	3.73	3.766	7.12	38
	5	72.7%	3.64	3.247	76.4%	3.82	2.763	13.88	2
	6	56.4%	2.82	4.200	60.0%	3.00	2.828	8.45	28
	7	41.8%	2.09	3.303	54.5%	2.73	3.191	5.70	50
	8	58.2%	2.91	2.985	63.6%	3.18	3.104	9.26	17
	9	60.0%	3.00	3.464	54.5%	2.73	3.766	8.18	33
	10	40.0%	2.00	3.464	58.2%	2.91	3.593	5.82	49
Manifolds Room	11	38.2%	1.91	2.985	76.4%	3.82	3.693	7.29	37
	12	47.3%	2.36	3.542	83.6%	4.18	3.693	9.88	11
	13	58.2%	2.91	3.303	54.5%	2.73	3.490	7.93	34
	14	63.6%	3.18	3.104	41.8%	2.09	3.593	6.65	44
	15	58.2%	2.91	3.303	74.5%	3.73	3.191	10.84	7
	16	61.8%	3.09	2.216	78.2%	3.91	2.216	12.08	4
Master Alarms	17	45.5%	2.27	3.191	74.5%	3.73	3.191	8.47	26
	18	58.2%	2.91	2.629	74.5%	3.73	3.191	10.84	7
	19	58.2%	2.91	2.216	80.0%	4.00	2.449	11.64	5
Medical Air Treatment Systems	20	43.6%	2.18	3.104	78.2%	3.91	3.303	8.53	25
	21	54.5%	2.73	3.191	54.5%	2.73	3.490	7.44	36
	22	58.2%	2.91	2.629	41.8%	2.09	3.593	6.08	47
	23	54.5%	2.73	2.486	78.2%	3.91	3.593	10.66	9
	24	54.5%	2.73	3.490	65.5%	3.27	3.766	8.93	21
	25	41.8%	2.09	3.303	80.0%	4.00	2.000	8.36	31
	26	45.5%	2.27	2.486	78.2%	3.91	3.303	8.88	22
	27	61.8%	3.09	2.629	56.4%	2.82	3.411	8.71	23
Outlets and Inlets (terminal units)	28	49.1%	2.45	1.651	78.2%	3.91	2.216	9.60	13
	29	41.8%	2.09	2.985	65.5%	3.27	3.191	6.84	41
	30	56.4%	2.82	3.693	74.5%	3.73	3.490	10.50	10
	31	58.2%	2.91	3.303	65.5%	3.27	2.486	9.52	15
Piping Network	32	74.5%	3.73	2.486	78.2%	3.91	1.706	14.57	1
	33	56.4%	2.82	3.104	61.8%	3.09	2.985	8.71	23
	34	58.2%	2.91	3.861	61.8%	3.09	3.303	8.99	20
	35	56.4%	2.82	2.763	43.6%	2.18	3.104	6.15	46
	36	38.2%	1.91	1.706	65.5%	3.27	3.766	7.64	45
	37	63.6%	3.18	2.763	61.8%	3.09	2.216	9.83	12
	38	54.5%	2.73	1.477	61.8%	3.09	0.953	8.43	30
	39	74.5%	3.73	2.045	61.8%	3.09	2.629	11.52	6
	40	63.6%	3.18	2.763	60.0%	3.00	2.449	9.55	14
	41	45.5%	2.27	2.860	74.5%	3.73	2.486	8.47	26
Vacuum Pumps	42	36.4%	1.82	1.279	74.5%	3.73	3.191	6.78	43
	43	38.2%	1.91	2.629	61.8%	3.09	3.303	5.90	48
	44	56.4%	2.82	3.104	54.5%	2.73	2.860	7.69	35
	45	36.4%	1.82	2.374	61.8%	3.09	3.861	5.62	51
	46	36.4%	1.82	1.279	76.4%	3.82	2.374	6.94	40
Valves	47	80.0%	4.00	3.464	63.6%	3.18	1.279	12.73	3
	48	43.6%	2.18	3.104	76.4%	3.82	2.763	8.33	32
	49	61.8%	3.09	4.573	34.5%	1.73	2.045	5.34	52
	50	56.4%	2.82	2.763	60.0%	3.00	1.414	8.45	28
	51	61.8%	3.09	4.112	60.0%	3.00	2.449	9.27	16
	52	45.5%	2.27	2.045	60.0%	3.00	1.414	6.82	42

, the evaluation of each maintenance issue for its probability and impact is shown. Resulting from these inputs, a standard deviation was calculated to reflect the dispersions of data. The results show an expedient level of compactness which reinforces the practicality of the data and its use. Table 3 indicates the ranking of maintenance issues based on RI values.

According to the experts, the most critical design-caused issue is the absence of future measures for expansion in the pipeline, which leads to multiple cutting-outs, bearing the highest RI. The availability of alternate bulk tanks was ranked second, far ahead of the remaining maintenance issues of the bulk systems. In a similar way, the maintenance shutdowns that force healthcare operations to suspend came in third among all the 52 issues, and it spearheads the issues of the valves. To describe one system as the most vulnerable system, it would mean the consideration of the summation of RI value for all the issues within each system, namely, the pipeline network. Second to the pipeline systems, the bulk systems show a high risk value for the overall maintenance issues identified. On the other hand, the master and area alarms have the lowest risk values. Cronbach’s alpha was calculated to assess the reliability of the questionnaire’s results. The overall probability and impact of all systems were tested separately, and they have the values 0.92 and 0.98, respectively. Values over 0.7 indicate that the results are reliable and consistent [86].

5. Discussions

Although design codes exist, the experts conveyed a serious message, which is that the best practices are not always followed when it comes to designing new healthcare facilities. In our analysis of the results, it is shown that current healthcare facilities tend to save costs by reducing their spending on some underestimated essentials. All the experts emphasized the importance of three main dilemmas, which are emergency supply sources availability, future expansion consideration, and accessibility of maintenance. These dilemmas engender most of the maintenance issues reported in this study. As the highest maintainability risk, multiple cuttings of a pipeline in cases of expansion cause a larger part of the system to shut down for modifications or maintenance, and cause the risk exposure to contaminants. This exemplifies a common issue in which designers insufficiently consider future expansions. These dilemmas occur as results of the design stage. The influence exerted by owners of facilities to alter design priorities for the purpose of cost saving is believed to be major. However, this study presents the observations of practitioners which address the cost impact over the long term. For instance, a future expansion could be taken lightly in the early stage. However, it has been presented that the absence of such measures will present an issue later.

Secondly, existing hospitals tend to limit outlets. Some parts of healthcare facilities need to intensify the presence of the supply of MGPSs, such as small operation theatres, pre-operative rooms, CT scan rooms, MRI rooms, and triage rooms. An ICU will be one of the sections that receives a pandemic surge. Thus, it must be fully equipped with additional MGPS availability. Another critical issue regarding terminal units: the durability of materials used in outlets and their seals has raised some issues. Frequent plugging in and unplugging can lead to rapid wear of outlets and their seals. Due to the optimization of costs and the continuous development of materials composites, materials selected for outlets and seals may have been introduced recently and not proven their heavy-duty capabilities. There are other instruments that are outside an MGPS, but connect to it, and may be associated with some of the issues raised, such as hoses, flow meters, and regulators.

Designers’ decisions impact operational effectiveness as well. The third maintainability risk involves the designer’s successful understanding of the shutdown schemes in healthcare facilities. Certain layouts of valves will cause operations to shut down, affecting the sustainability of healthcare services. In a similar way, the inclusion of a BMS is signaled as a worthy investment in the design stage, which will positively impact the facility management operations. Nevertheless, one expert expressed some concerns about the fire alarm system’s connection with a BMS, which was that it could suspend oxygen supply by accident without a fire case, which is a dangerous situation. Further, new healthcare facilities reported some cases of limited service space in the ceiling voids, which hinder the accessibility of maintenance and increase complexity for both maintenance operations and future expansions. The results affirmed the widespread maintainability issue in the design: insufficient consideration for maintenance. Maintenance accessibility to all components of an MGPS, which allows free space for ingress, egress, and movement to repair, replace, or checkup is highlighted. Not only knowledge of maintenance operations is mandated, but also healthcare operations. A vacuum system is crucial in medical operations. In addition to providing suction, it pulls liquids and solids, and a poor vacuum slows down medical procedures. If delays occur because of poor vacuum, this involves health and cost issues due to the time-based cost of operating theatres.

COVID-19 apparently changed a lot about MGPSs. Some issues were not priorities. One example is providing an external connection to the central oxygen piping system, to which an oxygen tanker truck can supply emergency oxygen directly to the system. This issue is associated with other elements of maintainability, such as the design consideration for the area specified for the bulky tanks’ yard. The urgency created by pandemics is sometimes beyond control. Enhancing the capacity, use points within facilities, and rapidity of expansions are the main domains for after-COVID-19 healthcare facility design.

The design-related omissions entangled construction phases in the causation of maintenance issues. A number of these issues were interpreted as design shortcomings that force construction crews to improvise and incorrectly execute parcels of work. In some cases, improper coordination for systems installation may be caused by design [18]. One example of the seriousness of this is the cross-connection of gases, which is widely recognized as a deadly risk if harmful gases are involved. The RII of the impact of this issue was recorded at 80%, where 7 out the 11 experts unequivocally named it a catastrophic event. The design shall consider all scenarios in which cross-connection may happen by prescribing components that are as gas-specific as possible. Additionally, the complexity of MGPS upgrades takes a toll, considering that many healthcare facilities have expanded over the years without proper as-built drawings [87]. Intensive engineering should be conducted to lay out accurate 2-D, 3-D, and labeling for all the existing equipment, pipes and valves, sensors, and outlets.

This study differs from other maintainability studies because it focuses not only on healthcare facilities but on a particular system, i.e., the MGPS. Although crucial to healthcare facilities, previous studies that investigated the maintainability of healthcare facilities have not sufficiently approached the MGPS. Hence, the maintenance issues presented in this study will add to the developing research on the maintainability of healthcare facilities. For example, de Silva and Ranasinghe’s maintainability study on healthcare facilities approached housing buildings and defined several maintenance issues [34]. As presented earlier, this study differs from other maintainability studies that included several building services systems but have not investigated MGPSs [14,34,35,36,37]. Another study conducted by Barbarosoglu and Arditi analyzed the maintainability of a single MEP system, i.e., the boiler system, and developed a BIM tool that helps designers to improve the maintainability of this system [88]. In a similar study by Marzouk and Hanafy, a BIM tool was developed to improve maintainability, which addressed some design criteria; however, it did not provide input on the maintenance issues that might arise [44]. The compilation of maintenance issues and their causes in this study is a main difference from the studies reviewed in this research.

6. Conclusions

According to the practical experience of experts, this paper assessed the maintainability risks of design-caused maintenance issues in MGPSs. Those issues were identified based on the literature and then refined by experts through semi-structured interviews. The experts selected for this study were qualified to provide critique and evaluation of the probability and impact of each maintenance issue. All the possible impacts, from operations disruptions, maintenance costs, and healthcare risks were considered. A total of 52 issues were identified along with their possible causes and evaluated by experts to arrive at an RI signaling the criticality of each. The most soaring predicaments that engender maintenance issues are emergency supply sources availability, future expansions consideration, and accessibility of maintenance. The three most critical design-caused issues are the absence of future measures for expansion, resulting in multiple cutting-outs, the unavailability of alternate bulk tanks, and the maintenance shutdowns that disrupt healthcare operations. While at the design stage, the designers can use the output of this research to optimize their design selections. For instance, the highlighted most critical issues should be at the epicenter of design decision-making.

MPGSs are one of the vital systems in healthcare facilities, and the optimization of the facility management stage from the outset is presented as a priority. The elimination of unfavorable design decisions and an awareness of recurring issues triggered by design errors and omissions can help to achieve higher maintainability.

This study has some limitations. First, the MGPS maintainability studies are scarce, which provides less comparable benchmarking data. The authors collected data from various research publications, case studies, and reports; however, the experts helped to shape a major part of the understanding of MGPS maintenance. On the other hand, the authors maintained, as much as possible, a balanced analysis of the input and evaluation provided by experts. Second, the study took place in a specific location, which doesn’t necessarily coincide with other geographical locations.

Future research in this field is necessary to promote the maintainability of MGPSs. This study sheds light on design-caused maintenance issues and provides clues for further investigation about the construction and maintenance practices that will reinforce the literature on MGPSs and spread more awareness. Moreover, extending design tools utilizing building information modeling (BIM), providing maintainability checklists for construction crews, or detailing improper maintenance practices all take a part in optimizing maintainability. Finally, quantitative studies that are built using real-life cost data are an important dimension of future MGPS studies.