Safety & loss control: Underwriting healthcare construction projects

SPEAKER: Welcome to the WTW podcast, Construction Blueprints, where we discuss the latest risk management and insurance trends, as well as issues facing the construction industry. We'll speak with a variety of construction leaders and experts on global topics, who can help provide you a blueprint for building your industry knowledge.

KEITH LAZARCHIK: Hello, and welcome to our Willis Construction Blueprints podcast. I'm Keith Lazarchik, Project Development Leader for North America, your podcast host, and I'm delighted to be joined by Robert Azarian, our Head of Loss Control for Willis Construction.

In this episode, we will explore underwriting health care construction projects and specifically from a safety and loss control perspective. The health care industry continues to experience significant growth. In fact, health care construction spend is over 69 billion in the US, up more than 37% over the past five years.

This is being driven by evolving patient needs, a shift to more outpatient facilities, and the need for more energy efficient and technology proficient buildings. There's also rising demand to replace aging facilities that are too expensive to bring up to code, and/or they need rightsizing.

Today's projects face heightened challenges related to safety, regulatory compliance, technology integration and cyber concerns, making risk management and planning essential for successful outcomes. That said, the insurance market has a strong appetite for health care risks, especially when the owner and each of the project's stakeholders are aligned on risk management and prepared to provide the underwriting community with accurate, comprehensive details about the project. And today, we will talk a bit about health care-specific underwriting factors. Bob, I'll turn it over to you.

ROBERT AZARIAN: Thank you for having me, Keith. I'm looking forward to this discussion.

KEITH LAZARCHIK: So, Bob, what are some of the top risks specific to health care construction. What keeps underwriters up at night when they're reviewing these projects?

ROBERT AZARIAN: Before diving into the health care-specific exposures, it's important to recognize that every construction project, including health care construction, is still fundamentally impacted by OSHA's focus for hazards, falls, struck by electrocutions, and caught between.

Of those four, falls continue to be the leading cause of fatalities in the construction industry year after year. Despite advancements in training, technology, and fall protection systems, fall-related incidents remain one of the industry's most persistent and deadly exposures.

Electrocution hazards, while statistically less frequent, often produce catastrophic outcomes when they do occur. In health care environments, that risk can become significantly amplified because contractors are frequently working around high voltage electrical infrastructure, emergency backup systems, and critical life safety equipment that in many cases, simply cannot be shut down during construction activities.

Unlike a typical commercial project where power can be isolated, hospitals often require systems to remain operational 24/7 to support patient care and life safety. But in health care construction, worker safety is really only half the equation. The other half, and arguably one of the greatest exposures from both a liability and operational standpoint, is protecting the public, facility occupants, patients, and maintaining uninterrupted life safety systems throughout construction.

Quite honestly, these are the types of risks that keep underwriters awake at night. One challenge we frequently encounter is that many contractors focus primarily on OSHA compliance, which is understandably because of OSHA regulations designed to protect workers and employees.

However, what many fail to recognize is that OSHA is not specifically intended to protect the public, patients, or visitors. There are relatively few comprehensive regulations focused exclusively on public protection during construction operations. Some cities and states have implemented stronger public safety requirements, others have not. And in many situations, contractors may need to rely on broader ANSI standards or industry best practices to help bridge those gaps.

Health care construction introduces an entirely different level of operational complexity and risk management. Some of the more significant exposures include protecting facility occupants such as doctors, nurses, staff, and support personnel, protecting patients, many of whom may already be physically vulnerable, immunocompromised, or identified as a fall risk due to their medical conditions.

Protecting visitors, outpatient populations who may be unfamiliar with the facility layout or any new facility layouts due to the construction, maintaining uninterrupted access and egress for emergency vehicles and ambulances, which can create major logistical challenges for staging, material handling and construction deliveries.

Controlling, and in many cases, completely eliminating noise, dust, vibration, and moisture intrusion. In health care settings, it's often not enough to simply minimize these exposures, because even small disruptions can negatively impact patient care, sterile environments, or sensitive medical procedures.

Fire safety efforts become especially critical, including reducing or eliminating hot work, tightly controlling combustible material storage, and ensuring waste is removed on a daily basis without disrupting hospital operations. Security becomes elevated when construction occurs near pharmacies, medication storage areas, data systems, or other restricted access space.

Crane operations and major material handling activities create additional exposure, particularly in dense populations. Demolition activities can expose workers to highly unique, rarely encountered on standard commercial projects. This may include abandoned laboratory piping, hazardous material contamination, regulated chemicals, radioactive or nuclear-related medical equipment, battery storage areas, and other highly controlled environments.

One of the most critical exposures is maintaining and protecting primary electrical systems, as well as backup redundancy systems during construction. And finally, perhaps the single most important exposure is maintaining strict infection prevention and infection control measures through every phase of the project.

Health care construction is unique because the project isn't simply about building or renovating a space, it's about performing high-risk construction activities while simultaneously protecting human life, maintaining critical operations, and ensuring the facility can continue delivering patient care without interruption.

KEITH LAZARCHIK: So, Bob, you touched on it briefly in that last answer. Construction and active hospital sounds incredibly challenging. So how do teams manage the infection control piece? One of the top concerns is construction happening while patients are receiving care. Can you explain what infection control risk assessment, ICRA, actually entails, and what happens when a contractor doesn't have adequate dust containment, negative air pressure, or sterilization protocols in place?

ROBERT AZARIAN: Well, construction work and hospital operations are probably two of the most opposite activities you could imagine occurring side by side, which is exactly what makes health care construction one of the most challenging environments in the industry from a risk management perspective.

Traditional construction is inherently disruptive. Noise, vibration, dust, debris, odors, and heavy material movement are all normal parts of the process. On most projects, those exposures are manageable. However, when the same work is taking place inside or adjacent to an active health care where vulnerable patients may be recovering from surgery, undergoing chemotherapy, or living with compromised immune systems, the stakes change dramatically.

In health care, something as simple as uncontrolled dust can become a life safety issue. Disturbing ceiling spaces, walls, or mechanical systems can release contaminants, mold spores, bacteria, or airborne particulates that may seriously impact patients. That is why infection prevention becomes just as important as the actual construction itself.

As you said, the primary framework used to manage those risks is what's known as an infection control risk assessment, also commonly referred to as the ICRA. An infection control risk assessment is a multidisciplinary and systematic process used in health care settings to identify and control the potential transmission of airborne and waterborne pathogens.

The ICRA serves as the governing document that establishes the required precautions and protective measures necessary to safely perform the work while maintaining ongoing hospital operations. One of the best industry resources supporting this process is the American Society for Health Care Engineering, commonly known as the ASHE, which provides extensive guidance, education and industry-best practices related to health care construction and risk management.

The ICRA process is designed to proactively identify hazards before work begins. There are several core components which are typically in the ICRA process. First, an ICRA team is assembled. This is a collaborative effort involving infection prevention specialists, hospital facility management personnel, safety professionals, and project managers and contractors, as well as nursing leadership.

Health care construction cannot operate in silence. Coordination and communication between all stakeholders is absolutely critical. Next, the project scope is evaluated. Activities are classified based on the type of work being performed, and that could range from minor inspections or maintenance activities, all the way to major demolition and invasive construction operations.

The surrounding population is also assessed. Certain areas within a hospital carry significantly higher risk than others. For example, administrative office areas may be considered low risk, while intensive care units, operating rooms, oncology departments, neonatal intensive care units are considered high risk.

Once these factors are identified, the ICRA matrix is applied. This matrix combines the type of construction activity with the patient risk group to determine the required level of precautions and containment measures necessary for the project.

Finally, the ongoing monitoring and enforcement becomes essential. The ICRA is not simply a document created during pre-construction and forgotten. It is a living process requiring continuous improvement, documentation, air monitoring, cleaning verification, and daily coordination.

The precaution levels themselves are generally categorized into four categories. A class I represents minimal impact activities such as non-invasive work or minor maintenance. Even at this level, precautions still matter. Workers may utilize HEPA vacuums, maintain clean work areas, seal doors as needed. Never dry sweep dust or debris.

Class II introduces more active dust-generating work and requires stronger controls, as well as air scrubbers introduced to prevent contaminants from migrating into occupied spaces. Class III involves significant exposure. Often includes constructing airtight temporary barriers, isolating HVAC units, maintaining verified negative air pressure, and establishing controlled access points.

Class IV represents the highest level of infection control and is commonly associated with major demolition. These setups include full containment systems, decontamination chambers, dedicated cleaning stations, and highly controlled worker entry points. In many ways, these containment efforts might resemble asbestos abatement operations due to the level of environmental control needed.

Another extremely important component of health care is training. Contractors and trade workers performing renovation must fully understand not only how to build the project, but how their work can directly impact patient safety.

Organizations such as the CPWR, the Center for Construction Research, offers an eight-hour ICRA awareness training certification program specifically designed to educate contractors on these unique challenges. Their training covers major topics such as containment, negative air systems, HEPA filtration, utility shutdown coordination, and practices within occupied health care environments.

These programs are valuable because they bridge the gap between construction and health care infection prevention. They help workers understand that maintaining a clean barrier or preserving negative air pressure is not simply a requirement. It may directly protect a patient's life.

Now, you asked what happens when a contractor fails to implement adequate dust containment, negative air pressure, or sterilization protocols. Well, that answer is easy and straightforward. You do not work. In health care construction, infection prevention controls are not optional. If the required containment are not functioning properly, if negative air pressure cannot be verified, or if barriers become compromised, work stops immediately.

Unlike many other construction environments where deficiencies may create productivity impacts or property damage exposures, failures in health care construction can directly affect patient health and safety. That is why hospitals, infection prevention teams, and project leadership takes these controls seriously.

At the end of the day, successful health care construction is not just about building a project safely, it's about building it while protecting the people inside the facility who are often as their most vulnerable.

KEITH LAZARCHIK: So, Bob, what makes health care construction projects unique is exactly that patient care and patient safety. So how do you protect patients when construction work threatens essential hospital utilities? When you're working in a project that could disrupt power, oxygen, water, HVAC systems to patient care areas, what are the backup plans or redundancies that should be in place? And then have you ever seen any real world example of things that went wrong?

ROBERT AZARIAN: Well, Keith, protecting patients during construction that affect critical utilities requires a layered risk management approach. It's not one control. It's a system of controls working together. The first part is pre-construction risk assessment. Similar to an ICRA, the PCRA, everything starts before work begins.

This assessment typically evaluates impact to patient care operations, critical care units, medical gas systems, HVAC performance, pressure relationships, electrical distribution and emergency power, redundancy power, fire protection systems, nurse call and communication systems, egress routes, and infection prevention controls.

The goal here is simple but critical, identify risk before it becomes disrupted. In health care, you don't discover impacts during work. You anticipate them in advance. So identifying individually which utilities will be impacted is critical.

Once risks are identified, the next step is understanding dependencies as much as at a deeper level. This is where construction teams, staff, and clinical leadership come together to map exactly what systems patients rely on and what happens if those systems go down.

For example, ICU patients dependent on ventilators and stable air systems. Operating rooms require strict pressure differentials. Dialysis units are dependent on water quality and pressure. Medication storage requires continuous refrigeration. Imaging systems are reliant on cooling infrastructure. Medical gas continuity for anesthesia and respiratory care.

At this stage, accuracy is everything. Mislabeling a valve or misunderstanding a shutdown boundary isn't a construction error. It could become a patient care event. That's why utility verification and clear isolation procedures are non-negotiable.

Then you have what's called planned shutdown procedures. A properly managed shutdown doesn't happen the day before or two days before an operation. It could happen weeks or months before the operation even begins. You need to have a written program, a multidisciplinary approval process, a detailed method of procedure, infection prevention review and sign off, engineering facility validation, coordination with hospital leadership, advance notification to affected departments, and defined contingency and rollback procedures.

Next, you have what's called redundancy and temporary utility support. Before any critical system is taken offline, a redundancy must be in place. In health care construction, temporary utility systems are often installed and tested before the first disruption occurs.

Common solutions are backup generators, temporary medical gas manifolds, portable temporary air handling units, HEPA filtration, temporary nurse call communication systems, temporary fire alarm coverage, portable water systems, and battery backup systems for sensitive equipment.

When possible, hospitals will also isolate only the smallest functional area necessary, reducing exposure to patients and limiting the operational footprint of the work. In many cases, critical loads are transferred to emergency power well before construction activity begins, ensuring stability of the primary systems compromised.

And then there's also what's known as emergency contingency planning. No shutdown or utility disruption should ever proceed without a clearly defined emergency contingency plan. In health care environments, planning for failure is just as important as planning for success.

And you had asked about real world examples. Well, in the health care facilities industry, utility failures are often associated with major natural disasters, events like hurricanes, floods, or earthquakes that disrupt primary power sources and put strain on backup systems.

But just as important and often more preventable are the failures that occur during construction activities inside active hospitals. One of the most common reoccurring issues involves HVAC systems and pressure control failures, including loss of negative pressure in isolation rooms, improper reconnection of ductwork, and dust migration into sterile environments.

In some cases, pressure relationships critical to infection control have been compromised entirely. When you look at root causes, a pattern quickly emerges. These failures are typically not the result of a single technical breakdown, but rather process gaps such as inadequate control of above ceiling work, poor communication during HVAC shutdown, or failure to fully verify system performance after restart conditions are met.

The key lesson learned here is straightforward but often underestimated. Commissioning and recommissioning verification is just as important as the shutdown planning process itself. Turning a system back on is not simply the reverse of shutting it down. It requires deliberate validation that it is functioning exactly as intended within a sensitive clinical environment.

Another less frequent but far more consequential issue involves medical gas systems, particularly oxygen and other critical gas delivery infrastructure. There have been several documented incidents where medical gas lines were misidentified during shutdown activities, improperly reconnected after renovation work, or compromised due to valve isolation errors. Unlike HVAC issues, these events have the potential for immediate and severe patient safety consequences.

The central lesson is that medical gas systems demand an exceptionally high level of control, strict labeling requirements, rigorous verification protocols, and independent testing prior to restoring service. Ultimately, these events reinforce a critical point in health care construction risk management. Resilience is not just about having backup systems in place. It's about ensuring those systems remain correctly identified, properly isolated, thoroughly tested, and fully verified at every stage of the construction lifecycle.

KEITH LAZARCHIK: What do carriers look at when evaluating a new project related to health care.

ROBERT AZARIAN: Well, mostly high rated insurance carriers are very diligent in how they conduct their risk assessment process. From an underwriting perspective, their engineers and risk consultants rely heavily on detailed field evaluations and written reports to help determine overall risk quality, underwriting appetite, and ultimately, the terms, conditions, and pricing they are willing to offer.

At a high level, there are several best practices that can significantly improve outcomes during this process, regardless of industry, but they are especially relevant in construction and complex operational environments such as health care.

First, it is critical to involve ownership and executive leadership directly in the risk assessment process. When senior leadership is engaged, it sends a strong message to carriers that safety and risk management are not delegated responsibilities. They are core organizational priorities. Carrier engineers want to see evidence that ownership is actively driving the safety culture, not just simply reviewing it after the fact.

Next, anticipate the underwriters and risk engineers questions before they are even asked. A well-prepared organization effectively answers those questions in advance through documentation, data, and clear narrative. When uncertainty exists, your broker should be leveraged as a strategic partner to help identify potential underwriting concerns ahead of time so you can proactively address them.

It is also essential to do your homework and your loss history and detail, including OSHA citation history, DOT compliance history, any relevant building or code enforcement violation. Most carriers will independently verify this information. However, what they often are more interested in is not the violation itself, but what corrective actions and loss prevention measures were implemented afterwards to ensure it does not reoccur.

Whenever possible, do not simply restate OSHA requirements when discussing your safety programs. Instead, highlight where your organization exceeds regulatory minimums. Demonstrating performance beyond compliance is one of the strongest differentiators in a competitive insurance market.

Do not be hesitant to actively market your safety program. While it may feel uncomfortable for some organizations, effectively communicating your safety culture is not boasting. It is risk positioning. Provide real examples of what your company or why your company is unique, including both strengths and areas where you are actively improving. Carriers, value, transparency, far more than perfection.

It is also important to emphasize what your company does as a standard practice, rather than focusing solely on client-driven requirements. Client-specific safety requirements may not always be consistently applied across all projects or operations.

However, internally-driven standards reflect your true organizational commitment. That said, where owner or client requirements are effective, consider elevating them into your company wide baseline when practical.

Do not hesitate to request feedback from your carriers and risk engineers, even if you do not ultimately implement their recommendations. Many carriers do not provide formal external reports to prospects, but internally, they often generate detailed assessments that include concerns, observations, and sometimes scoring.

Gaining insight into how you are being evaluated can be extremely valuable when preparing for future renewals. This becomes particularly important in a cyclical and highly variable insurance market. Appetite shifts year to year, and in some cases, you may have multiple competitive options, while in others your choices may be limited.

In those tighter markets, you want to ensure that none of your limited options are internally categorizing your risk profile as substandard. Additionally, ensure your safety programs are not just well-written documents, but living systems in practice.

Equally important is maintaining a balanced approach between safety recognition and disciplinary accountability. Carriers often request examples of both. When would recognition last issued for positive safety behavior and when was disciplinary action taken? Many organizations are surprised to discover that while policies exist on paper, there is little evidence of consistent implementation in practice. Consistency is key.

Now, when we look specifically at health care, most in construction environment expectations become even more rigorous. Most carriers will focus heavily on several key areas, many which we already discussed. First, strong subcontractor pre-qualification processes are essential, particularly those that evaluate prior health care construction experience. Working in active health care facilities requires a very different level of coordination.

Second, carriers expect core training programs tailored specifically to health care environments for both field workers and supervisory personnel. This includes understanding infection control, patient safety considerations, and facility operational constraints, and several of the already mentioned safety training resources.

Third, robust orientation procedures are critical. These should include safety training specific to the facility, issuance and control of identification badging, and where possible, background checks and drug and alcohol testing. These measures help ensure a higher level of workforce, reliability, and site integrity.

In addition, clear and enforceable controls must be in place to separate construction activities from active health care operations. This includes physical barriers, access control measures, and defined work zones to protect patients, staff, and visitors.

Finally, there is an increasing expectation for the use of technology. This includes tools to monitor air quality, track environmental conditions, and manage restricted access in real time. Technology is becoming a key differentiator in demonstrating proactive risk control in sensitive environments like health care.

From a construction and safety and loss control perspective, the strongest health care construction programs typically share these characteristics, early involvement of clinical stakeholders, conservative shutdown planning, redundant utility protection, formal permit systems, clear escalation of authority, detailed contingency planning, strong infection prevention integration, and continuous field verification. In health care construction, a successful operation is one where the patient's never realized the risk existed.

KEITH LAZARCHIK: Bob, advancement in technology is another key aspect of safety and loss control. Have you seen any use of technology in this area that has provided positive impact to safety and loss control?

ROBERT AZARIAN: Well, technology is running rampant. Technology is moving faster than ever in today's construction and risk environment. And with the acceleration comes a wave of buzzwords, AI, AI, AI, wearable technology, KPIs, and many more.

At this point, it feels like every tech startup in the safety space is trying to anchor their pitch around AI. And frankly, if had a penny, for every time I've seen AI-powered safety solutions in the marketing deck, I'd be a very wealthy safety professional.

What's even more interesting is the cycle of innovation I've observed. Several companies that were making noise just a few years ago are no longer around. At the same time, new entrants continue to emerge almost weekly. So while the space is active, very active, it's still evolving and not everything is sticking.

That said, I'm starting to see certain tools and methodologies gaining real traction with contractors and developers. In many cases, they're not just experimenting anymore. They're piloting with intent and in some cases, scaling across projects.

Now, I would still say the industry is too early in the maturity curve to definitely claim widespread, measurable reductions in claims purely driven by technology. But where I am seeing consistent improvement is in the efficiency, documentation quality, and administrative effectiveness.

And that last point matters more than people realize, because any technology that can give a safety professional an extra hour away from his desk is an hour gained in the field. Observing work, coaching crews, identifying hazards early, and reinforcing positive behaviors, that's where the real safety impact happens.

So what types of technology am I seeing today? Well, a few of them. I'm seeing a lot of use of QR code-driven field process. One of the simplest, most effective tools is gaining traction, is using these QR codes directly on equipment, scaffolding ladders and lifts requiring workers to scan a QR code and complete a safety inspection. It streamlines documentation, improves compliance, and reduces friction in the field.

We're also seeing QR codes being used like a digital suggestion box. On some projects, feedback isn't just limited to supervisors anymore. It's often open to workers, owners, and often, even the general public. That kind of accessibility can surface issues earlier and improve engagement across the board.

We're seeing a lot of use of AI and safety documentation and hazard identification. AI tools are increasingly being used to refine safety documentation, polishing inspection notes, improving wording and reports, and helping standardize communication.

More recently, these systems are starting to assist in identifying hazards beyond basic PPE issues. We're seeing them flag concerns like fall protection gaps, poor housekeeping, and sequencing risks. That said, caution is still necessary. These tools are evolving. They can miss context or misinterpret field conditions. So that should be treated as a support layer, not a decision maker.

Think of AI as a second set of eyes, not the final authority. Used correctly though, it becomes a useful checks and balance system that enhances, not replaces human judgment. We're still seeing wearable technology and field monitoring wearables are still in the mix, particularly for tracking fatigue, movements, and in some cases, even a fall from elevation.

However, they seem more of a niche market and more aligned with very specific needs. While adoption varies, the direction is clear, more real data tied to worker safety and site conditions. We're seeing a lot of video surveillance in AI-enhanced security systems being marketed.

Some insurance carriers are even encouraging or incentivizing video-based safety monitoring solutions as part of a broader risk management strategy. In the builder's risk arena where you have water, fire, and security as critical risk exposures, the carriers are increasingly focused on preventing high severity losses before they occur.

Water intrusion detection is arguably at the top of list right now. It's becoming one of the most common technology investments on the active projects. We're also seeing an increase in central station security systems, motion detection systems, portable infrared detection tools. We're seeing little portable IR cameras that can actually attach to your phone, and they're using them to monitor hot work activity, electrical systems and overheating conditions, as well as early stage water intrusions.

We also have some projects utilizing virtual reality systems, where they've actually created full VR models of their job site, intentionally introducing virtual mock hazards, and then having their supervisors respond by putting on the VR goggles and taking a test on if they're able to identify those hazards. It's a powerful training tool because it creates experience-based learning without real world consequences.

We're also seeing digital construction tools, 4D modeling. For health care, we're seeing a lot of automated line, air quality monitoring systems to be able to attack and help assist in identifying air quality and sensitive environments, as well as emergency planning systems designed to support rapid response and continuity planning.

Access is a huge area. Technology is being used both from turnstiles, retinal scan to get onto projects, and a lot of these systems are tied into software applications that can track training, training expiration dates, site access history. Some of them are tied into video surveillance so they can monitor who comes on and off the job sites.

And lastly, we also have a lot of use for safety data management platforms where you can track key performance indicators, claims performance, safety recommendation tracking, training records, job hazard analysis, to name a few.

We also see a few systems dabbling in predictive analysis tied in with AI, trying to help predict future risk based on historical performance. That's early stage development, but we are seeing a lot of firms and systems dabbling in that area.

So while the construction industry is still in the early stages of fully realizing the promise of emerging technology, the direction is clear. Better visibility, better communication, better data management will lead to better field execution.

KEITH LAZARCHIK: Bob, thank you for contributing this episode, and thank you for sharing your perspective on such an important topic.

ROBERT AZARIAN: Thank you, Keith, for having me. I appreciated this opportunity. I will also attach any links from the resources I mentioned during our discussion on our web page.

KEITH LAZARCHIK: Thank you to everyone that's listened. And thank you for joining the Willis Construction Blueprints podcast. We will talk to you on the next one.

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