Midwives returning to roots, building the future

The Lincoln Community Midwives are coming home to West Lincoln Memorial Hospital (WLMH).

As announced last week, the midwifery team will be returning to practice at the site on October 3, when the birthing service officially resumes in a 24/7 care model.

“We are all really excited to be coming back to WLMH. It feels like we are returning to our roots while being able to build the future of the program at the same time,” says Pilar Chapman, midwifery site lead for WLMH.

The WLMH obstetrics program has been temporarily redirected to Niagara Health a few times since 2019 as a result of necessary safety upgrades needed at the site, staffing shortages and response to the COVID-19 pandemic. The current redirect has been in place since December 2021, when the fast-moving Omicron variant spread across the site closing all but a few beds to new patient admissions.

Caring for the community

For a time during the program’s redirect, the midwives worked between both WLMH and Niagara Health providing care for patients. However, as the temporary pause lingered, the team made the difficult decision to stay at Niagara until the program could return 24/7.

“We tried working between the two hospital sites for a while, but it was not working well. There are logistical challenges when working between two different hospitals [sites and systems] each with their own processes. There are also concerns around moving patients in labour or with the possibility of being in labour when the changeover between hospitals happened. Most importantly, patients were stressed about the situation and we just decided to stay at Niagara Health until we could come back 100-per-cent of the time,” said Chapman.

The midwifery service has a long history at WLMH, dating back more than 25 years. WLMH was one of the first hospitals in the region to open its doors to midwives. At the time, the hospital had just one obstetrician practicing and the midwives brought additional support and growth to the program. Midwifery practice makes up an integral part of the interdisciplinary team at low-risk-birthing units working closely with obstetricians, family physicians and nursing colleagues.

“WLMH has traditionally offered a low-risk birthing focus. Midwifery care is a great complimentary service as it primarily deals with normal, low-risk births. We’ve had a great relationship with providers at the hospital for a long time,” said Chapman, noting that prior to the recent service changes, midwives delivered 15-20 per cent of all babies at WLMH.

New hospital, new opportunities

Chapman was quick to express gratitude toward Niagara Health and the team at its St. Catharines’ General site for welcoming them into the fold.

“Our team is very thankful for Niagara [Health] opening their doors to our practice during this period. They were very welcoming and our team has a great relationship with their labour and delivery unit.”

Being at the St. Catharines’ site also helped the seven-person Lincoln midwifery team appreciate the benefit of working in a newer hospital, increasing excitement about the soon-to-be rebuilt WLMH and the opportunities it will hold.

“We look forward to continuing to build a program focused on low-risk, normal births. As a teaching hospital, it holds the opportunity for incorporating further research and evidence into our practice. But we will also be able to teach other obstetrical care providers about this important care model, which can help low-risk birthing units thrive in smaller communities,” said Chapman, who also offered that there are very few Level 1B birthing units – WLMH’s designation – remaining in Ontario.

The midwives aren’t the only ones who are eager for the service to return. Many across the hospital community are counting down the days until the midwives resume practice at WLMH.

“We all are looking forward to a new beginning for our WLMH site,” said Dr. Joan Bellaire, WLMH site medical lead. “It is so momentous for us to welcome our midwives back to the WLMH family and to benefit from their knowledge and skill while working together with our obstetricians, family physicians and our nurses to guide our department towards a centre of excellence for low-risk obstetrics. Their decision to come back was critical in the program being able to return at this juncture.”

HHS obstetrical nurse training program a labour of love

In-house partnership “builds the teams we want and need” amid WLMH service pause, global staffing crisis

Nursing positions within the West Lincoln Memorial Hospital (WLMH) obstetrics program have historically been hard to come by. The program’s reputation and culture make it a place where many staff often start out of school, and then stay for their entire career.

When a spot opened up in August 2021, Courtney Davis didn’t miss the opportunity to throw her hat in the ring.

“It was hard to get in because nobody ever left,” said Davis, a registered practical nurse who spent the previous four years working at the site on a general medicine unit. “When I was hired in medicine at WLMH, the obstetrics program had a great reputation. I’d always considered working here.”

The birthing service has been temporarily redirected to Niagara Health a few times since 2019 as a result of necessary safety upgrades needed at the site, staffing shortages and response to the COVID-19 pandemic. The current redirect has been in place since December 2021, when the fast-moving Omicron variant spread across the site closing all but a few beds to new patient admissions. Last week, the hospital announced that the obstetrics program would reopen to deliveries at the site on October 3 in a 24/7 care model. The reopening follows months of necessary work to rebuild the program.

Recent hires into the program need to add or enhance their existing obstetrical skills in preparation for the fall return. But with limited volumes at WLMH due to the redirect, a unique in-house training program has been developed in partnership with the labour and delivery team at Hamilton Health Sciences’ McMaster University Medical Centre (MUMC), which is attached to McMaster Children’s Hospital.

The team at MUMC deliver approximately 4,000 births a year, many of which are high-risk.

Specific skill set needed

“When hiring a nurse to work in the obstetrical service, I’m really looking for a few things,” said Angela Leslie, clinical manager in WLMH’s obstetrics department. “First, do they have general nursing experience? Then, there are specific skills needed to be successful in the role like fetal heart monitoring, perinatal certificate and neonatal ressucitation.”

The in-house training is beneficial to the WLMH nursing team, and is also welcomed by the McMaster team as well.

“The advantage of having McMaster in our system with its volumes and nurses with such expertise is a fantastic learning opportunity. But it also benefits the McMaster team as well, bringing skilled nurses and a few extra sets of hands into the delivery rooms to help with those volumes has also been well received,” Leslie pointed out.

Caring for adults and babies


Even for experienced nurses like Davis, making the transition to caring for newborns has a learning curve as the role requires a 50/50 split in assessing and treating moms and babies.

“All of the assessments are different and all of the vital signs are different. Over eight years of nursing I’ve developed a ‘nursing intuition’ about things. Now we’re adding some specific skills needed to safely care for these little patients,” Davis noted.

Shyma Prince agrees. Originally trained as an obstetrical nurse in India, Prince brings significant operating room nursing skills to the WLMH obstetrics team, which she honed while most recently working at a hospital in Alberta.

“Since being hired we have mostly done c-section deliveries at West Lincoln. We have had the opportunity to work with the team at McMaster to assist with high-risk deliveries as well as upgrading post-partum care skills, caring for mothers as they heal from the delivery,” said Prince, a registered nurse who was hired in February 2022.

Team critical to success

According to Shasta Cividino, clinical manager in labour and delivery at MUMC, there are many experiential learnings beyond skills development which can also be gained through training opportunities like this partnership.

“Being a regional centre, staff get exposure to wide variety of normal low-risk and high-risk care. But they also have the opportunity to experience emergencies which will happen in every birthing centre. In those situations, developing the wherewithal to understand how the team can come together and work through a situation is very important,” she said, adding that there are many unique situations and cases a nurse will see only once in a 30-year career.

Another benefit of spending time in different clinical settings is the chance to build a community of practice with other nurses. A result Cividino calls the “phone-a-friend” mentality.

“Mentorship in health care can be sometimes hard to achieve, especially given the current generational shift going on. We have a wealth of people in that intermediate to expert range to talk and vent to and deconstruct scenarios with. This is great for workplace wellness. You can’t bring these conversations home because of confidentiality and privacy, which is where like-minded colleagues can really help you through those situations,” she said.

Hiring in a global staffing crisis

Finding experienced obstetrical nurses – or any specialty nursing position – is increasingly challenging in the current climate. Health care professionals are in short supply after what many sources attribute to two years of pandemic chaos across the sector. According to Leslie, training programs like this will be increasingly important.

“It’s extremely competitive out there trying to find staff,” she said. “For the obstetrics roles, we are looking at all angles to reach candidates where they are and where they are looking for work. We get candidates for every posting but most don’t have the complete skill set we need. We are fortunate to have in-house training opportunities to help build the teams we want and need.”

The intensity of hiring has also increased. Candidates have many options so they don’t wait too long for a hiring manager to respond to their inquiries. Fortunately, the promise of the new hospital continues to attract great candidates.

“The biggest selling point is the new hospital. Everyone wants to work in a state-of-the-art, smart hospital in a beautiful and growing community. It will allow us to further incorporate research and education into practice. We have a very bright future,” Leslie noted.

Over at MUMC, Cividino – who has held roles during her career at WLMH – believes the new hospital and the program’s reputation will be a perfect storm bringing many expectant mothers to the site to deliver.

“When the new hospital opens its doors, the team can anticipate a much busier obstetrical program with the attraction of a new site, exceptional care delivery standard and a growing community in West Niagara.”

Obstetrics services resuming October 3

Program rebuilding includes return of WLMH Midwives

The below is an abbreviated version of a staff and physician message shared on August 17, 2022

Starting October 3, the labour and delivery program will return to West Lincoln Memorial Hospital (WLMH) site, operating in a 24/7 model of care. This is the result of many months of work and significant recruitment efforts by multiple departments at the site and across Hamilton Health Sciences (HHS), to bring the service back in a sustainable manner. This was also made possible by significant partner contributions, including the WLMH Foundation and Niagara Health.

Specifics include:

• Physician coverage will be enhanced by a new obstetrician and gynecologist who will join the program on a six-month contract, with the possibility of extension for an additional four months.
• Following months of aggressive recruitment efforts, program staffing is currently sufficient to return based on expected near-term patient volumes. Recruitment will continue to ensure further coverage as volumes grow over the coming months.
• WLMH’s operating room team is also growing with the addition of new procedures and surgeries being delivered at the site, which will allow for a 24/7 call schedule to support urgent after hours obstetrical cases.
• As part of a return to 24/7 coverage, we are excited to welcome the WLMH Midwifery team back to the site. WLMH Midwives have been practicing at Niagara Health, and will provide care to expectant mothers, families and babies at WLMH starting October 3. Their presence will be an essential piece of the program’s transition back to the site by adding ongoing low-risk obstetrics mentoring to the nursing team, as well as for the long-term success of the program.

In addition, recruitment has progressed toward hiring two additional full-time OBGYNs to the program. Interviews will take place this fall. A team of four FT OBGYNs – the largest physician complement the program has ever operated – will add stability and predictability to the program, enabling long-term growth.

This period of temporary redirect has been longer than anyone expected or wanted. We are optimistic that the foundational rebuilding mentioned above represents the start of the program’s next chapter.

Thank you to our staff and physicians who remain committed to serving patients at the site and in this program, despite the many changes over the past few years. We would also like to acknowledge the WLMH Foundation which graciously provided the hospital with a grant to assist with OBGYN recruitment, in addition to its ongoing financial support of the program. Finally, we thank our partners at Niagara Health in caring for WLMH mothers and babies during this time.

WLMH key to HHS’ innovative surgical plan

Plan made possible through Surgical Innovation Fund

Three Hamilton Health Sciences (HHS) hospital sites are partnering to tackle wait times for certain spine, knee and eye day surgeries.

These surgeries currently have wait times longer than the provincial targets. This plan, made possible through $450,000 from the province’s Surgical Innovation Fund, will help reduce wait times overall.

This plan will see some day surgeries for adults currently performed at Hamilton General Hospital (HGH) and McMaster Children’s Hospital (MCH) move to West Lincoln Memorial Hospital (WLMH) in Grimsby.

Read the full story here.

“One call does it all”

Multi-year overhaul of diagnostic imaging equipment benefits from MES agreement

Change has been a consistent theme at West Lincoln Memorial Hospital over the past few years.

From an equipment perspective, the diagnostic imaging (DI) service has arguably seen the greatest amount of change during this time period. With the operating room renovations in 2020 came the new C-arm machine. Then the site’s first-ever computed tomography (CT) scanner opened for patient care in mid-2021. Immediately after, work got started on upgrading the mammography and two x-ray suites.

“We have all been so excited for so long to get two x-ray rooms open,” said Mindy Chmielewski, senior CT technologist at WLMH. “Prior to the renovation, we had two rooms and machines, but one of the machines could only perform a limited amount of procedures. That machine was also very old and the quality of images was not good. It was stiff and difficult to maneuver, which was a challenge for staff and posed significant risk for injury.”

The first renovated x-ray room opened in fall 2021. The second room became operational on February 14, essentially completing the multi-year DI overhaul at the site.

More machines, more efficiency

“Now that we have two fully functional rooms and machines, we can be far more efficient with patient care. We don’t have to wait for the other technologist to finish, we can just do our exams and get patients on their way,” said Amy Tousignant, senior x-ray technologist.

Chmielewski agrees. “When the emergency department was full and we knew we had a lot of patients requiring x-rays, it seemed like a really daunting task to coordinate in a timely manner with one machine. Now, it’s really easy and reduces stress in our day.”

Renovations, upgrades enhance safety

The x-ray suites themselves also got a makeover. The renovation included safety updates to the paneling inside the walls required to contain the radiation. The team also took the opportunity to reconfigure the space to improve overall function and safety, like adding a control room in between the two suites which lets staff monitor both rooms and easily assist colleagues in either when they need a hand.

“You can tell that function was definitely considered when they planned these renovations,” said Chmielewski, who added that the renovated rooms have received many “oohs and ahhs” from patients.

The new x-ray machines are fully automated meaning limited physical force is needed to operate.

“The ergonomic elements alone are amazing. Technologists are susceptible to injury from repetitive motions, particularly upper back injuries. These rooms and equipment are safer for staff and therefore safer for patients,” added Tousignant.

The renovation also repurposed an existing hallway into a staff room which Chmielewski, Tousignant and their colleagues call, “the team room.”

In June 2021, WLMH’s first-ever computed tomography (CT) scanner opened at the site.

CT scanner serving the community

The CT scanner saw its first patients in June 2021. Since then, the demand for the service has grown steadily. Currently, it is fully booked pretty much every day.

“We get tons of positive feedback from patients, largely about receiving care closer to home and decreased wait times for service. Patients also love the space and compliment us on the suite and facilities,” said Chmielewski. “We have received thank you cards from patients which I’ve never seen before in my career. It is a very rewarding place to work.”

All of the recent DI equipment has been procured through the landmark Managed Equipment Services (MES) agreement that Hamilton Health Sciences (HHS) made with Siemens Healthineers in early 2020. One of the most innovative pieces of the agreement is the built-in service component, which streamlines maintenance and limits machine downtime.

“MES has been really good. Each piece of equipment is labelled with a device ID number and a phone number for tech support. If anything goes wrong, we can easily get a hold of tech support around the clock to troubleshoot or schedule a maintenance call. One call does it all,” said Chmielewski.

Hospital under construction

All of this progress does not come without challenges. The noise and unavoidable chaos which comes with construction has been part of daily life at the site for many years.

“Working in a hospital under construction has been difficult. However, when I started here six years ago, it was clear how bad a state the hospital was in and how much work was needed. Yes, it can be a pain to hear the noise and have your workflow disrupted. But knowing that better things are coming, like the two new x-ray rooms, helps you get through it,” said Tousignant, who was quick to add that the construction team has been extremely courteous and respectful throughout the renos.

Diego Gomez knows this challenge all too well. As the project manager responsible for delivering all MES projects across HHS, he has worked closely with the construction team to sequence the projects at WLMH to minimize disruption while sticking to schedules.

“The feedback we have received about our contractors from staff and end users across the site has been excellent. It takes a lot of coordination from contractors, consultants, Siemens and site staff to execute these projects, but I feel like this is an example of great teamwork achieving great results,” said Gomez, pointing out that every project was completed on time and on budget.

Looking to the future

All of the DI equipment will carry over in to the new hospital. The future has been a shining light for many staff at the site.

“I’ve worked at different places but I’ve never had such a sense of team as I’ve seen here. It’s a positive environment and great atmosphere. We all know that things are going to get better in the new hospital and that the challenges of this building are now temporary. We’re a pretty resilient bunch,” said Tousignant.

WLMH welcomes Dr. Mosher, OBGYN

For Dr. Andrea Mosher, coming to West Lincoln Memorial Hospital is a bit of a homecoming.

“This opportunity at WLMH is somewhat full circle for me,” said Dr. Mosher, WLMH’s newest obstetrician and gynecologist. “I grew up in Niagara Falls, did my undergrad at Queens University, went to medical school in Calgary, and took my residency in Hamilton. I am excited for this opportunity to come back to the Niagara community.”

At a young age, Dr. Mosher set her sights on a career in medicine. Influenced by a family friend who was a physician practicing obstetrics in a low-risk birthing environment, she started considering a similar path for herself.

“Being a doctor was always a dream of mine. When I was in medical school I did rotations in obstetrics and I was then matched into the residency program. It’s an honour to be part of families’ birthing experiences and help them welcome a new life into their family and world,” she said.

Dr. Mosher is currently practicing at St. Joseph’s Healthcare Hamilton. She officially starts at WLMH on October 1. The community medical model in place at West Lincoln will be a change, but a welcomed opportunity to practice in a different care environment with new colleagues.

“The model is unique as it allows you to interact with many other providers from the hospital and community. This presents a great opportunity for continued collaboration and growth because it always keeps you learning and encourages experience sharing with each other. It’s very important to me that I’m always advancing but also helping others advance as well,” noted Dr. Mosher.

In addition to her expert clinical skills and experience, she brings another personal yet critical element to her practice which enhances her interaction with patients during their journey to parenthood.

“I’m a mother of two young boys. This is an important piece of who I am but also how I engage with my patients. Having my children let me learn what it was like from a patient’s perspective and where appropriate, I bring this into my work. While it’s definitely not a requirement for practicing obstetrics, personally, I feel like it helps me connect with new and expecting moms and parents,” she explains.

Dr. Mosher is also a practicing gynecologist and will continue this work at WLMH. Through her appointment at McMaster University, Dr. Mosher’s current research focuses on endometriosis – a common but underdiagnosed condition where endometrial tissue grows outside the uterus – with the goal of expanding knowledge of the symptoms toward earlier diagnosis and treatment.

When asked if she had a preference between her two specialties, she gave a considered chuckle before responding.

“I like to say: I came to the specialty for the obstetrics and stayed for the gynecology,” she said. “I really love them both and I think they complement each other well. I am excited to see that gynecology has significant [operating room] time allocated at WLMH and it will be great to get in there work through some of the backlog caused by the pandemic. Being able to help fill a clinical need for a community is humbling.”

The obstetrics program has been temporarily redirected to Niagara Health following a provincial directive earlier in the year which paused scheduled care and facilitated the redeployment of hospital staff to critical care and other clinical areas hard hit by the COVID-19 pandemic. WLMH staff who contributed to this response have since returned to the site.

Separately, in the past year, two of the site’s three obstetricians have departed to pursue professional opportunities abroad. Dr. Nwachukwu [ChuChu] Nwebube who leads WLMH’s obstetrics and gynecology department has remained steadfast in his role and has been the sole obstetrician/gynecologist on site for a number of months.

From an operations perspective, there are three essential pieces needed to run an obstetrics and gynecology program: operating room (OR) staff and OR availability, obstetrics staff, and obstetricians/gynecologists. Dr. Mosher’s arrival is a big step toward fulfilling the physician complement and resuming obstetrical care at the site starting October 5.

“We’re grateful to staff who took on different roles to help out across Hamilton Health Sciences sites during the pandemic, but we’re also really glad to have them back at the site,” said Cindy MacDonald, director of community programs and WLMH site administrator. “Our OR and obstetrical staffing has been stabilized. Dr. Mosher is passionate to work in the community and her arrival is an opportunity to rejuvenate the program. We’re excited for her to start, and at the same time we’re all incredibly thankful to Dr. Nwebube for his dedication and commitment to our patients and the program.”

Arguably, no one at WLMH is more eager for Dr. Mosher’s arrival than Dr. Nwebube.

“Over the last year, we’ve worked through the loss of two obstetricians and it’s very promising to welcome Dr. Mosher to the team,” he said. “She brings great expertise and talents to the program and to our patients. Her contributions will be important as we serve patients in the current building, but also as we transition to the new hospital and restore the program to its former glory and beyond. In addition to her clinical practice, she’s also an accomplished researcher and we’re looking forward to her bringing this important element to the care we provide.”

With the birthing program set to resume, consideration needs to be given that the COVID-19 pandemic is still very unpredictable in the community and the government-driven response which may be needed in the coming months is yet unknown. However, most people at the site are now looking a little farther down the road; to the opening of the new hospital.

“The promise of the new hospital holds a lot of potential,” said Dr. Mosher, who noted the prospect of a rebuilt WLMH played into her decision to accept this role. “It’s exciting to have the opportunity to work in a new facility which is being built with community growth in mind and patient care at the centre of everything. Also, the new hospital will let us further grow the obstetrics program and provide long-term stability for patients in the community.”

The WLMH redevelopment is currently in Stage 4 of the planning process, with the Request For Proposals (RFP) currently out to tender. Shovels are looking to hit the ground in June 2022.

Obstetrics services resuming October 5

Obstetrics services at WLMH will resume starting October 5, supporting deliveries from Tuesday morning to Friday afternoon.

Outside of these hours of operation, women in labour or requiring assessment will be redirected to deliver at the St. Catharines site of Niagara Health (NH).

This is the same model that was in place prior to the provincial directive earlier this year which temporarily paused scheduled care to allow hospital staff and physicians to support clinical areas hardest hit by the COVID-19 pandemic.

Our obstetricians and family physicians will retain their privileges at both hospitals, allowing continuity of care for patients. In situations where WLMH physicians are not able to attend a delivery, the patient will be under the care of the NH obstetrician on call


Midwifery care will be provided at NH only.

EXPECTING FAMILIES: this handout is for you.


Once again, the obstetrics service resumption will be assessed on an ongoing basis to determine if and how it can be extended. The goal is to provide as many hours of obstetrics services as possible, as long as its sustainable from a staffing and resourcing perspective to do so.

Hamilton Health Sciences is grateful for our ongoing partnership with NH and its team who continue to make this service arrangement possible until obstetrics services can fully resume at WLMH. We also appreciate the flexibility and professionalism our staff and physicians have demonstrated during this period of transition.

What’s Up @ WLMH: August 2020

WLMH ORs Reopening September 14

Critical safety upgrades required in the WLMH operating rooms (ORs) are now complete. Activity in the ORs will gradually resume, starting the week of September 14.

Patients will soon be able to receive high-quality procedures closer to home, in an environment that meets standards for safety and infection control.

Which services will be provided?

Services resuming in the coming weeks include:
• Endoscopy procedures
• Gynecology and general surgery cases, addressing the backlog created by the province-wide COVID-19 surgical shutdown
• Elements of obstetrics services, such as scheduled cesarean births

We continue to focus on building up OR nursing staff levels to increase on-call capabilities at WLMH and support more surgical services over time.

What does this mean for patients?

Patients will be contacted by their health-care provider about scheduling their procedures.

Additional information for obstetrical patients is available here.

We appreciate everyone’s ongoing patience and resilience while these necessary safety upgrades were taking place.


What’s coming up this fall?

Work is progressing on a number of priorities at the site. Here’s a look ahead to what’s happening in the coming months:

September

  • Surgical activity gradually resuming in WLMH ORs
  • Construction starts on CT scanner suite

October

  • Building a New WLMH – Stage 2 submission on track to share with Ministry of Health for review and approval

November

  • Two-Year infrastructure project wrapping up – three months ahead of schedule!

What’s Up @ WLMH: May 2020

Hospital services starting to gradually resume in Ontario

Earlier this week, Hamilton Health Sciences’ (HHS) plan to gradually resume clinical services was approved by Ontario Health. Many services, including surgeries and other procedures, were paused during the initial response to the COVID-19 pandemic. Here’s the message we shared with our staff.

This approval means we will now start gradually booking appointments for some procedures, prioritizing care for patients based on the severity and urgency of their medical needs. Patients will be contacted directly by the hospital or their doctor about the timing of their care, when an appointment for them is available.

West Niagara residents will continue to receive procedures at other HHS sites. The operating rooms at West Lincoln Memorial Hospital are undergoing critical safety upgrades and are scheduled to re-open this fall.

We will provide further updates as this process moves forward, but you can also stay up-to-date here.

Progress on important safety upgrades at WLMH

Completed:

  • Laboratory upgrades, like electrical, lighting and millwork
  • Parking lot resurfacing completed; lighting is being installed

Upcoming:

  • Work on Endoscopy Reprocessing starting June 1
  • Operating Room/Intensive Care Unit work starting June 15

West Niagara municipal Councils show continued support for the new WLMH

This month, local municipalities (Grimsby, Lincoln and West Lincoln) each passed a motion of commitment to the local share financing required for the construction of a new hospital. This commitment is a critical part of the hospital planning process. We thank each of the Councils and Mayors for their continued support of this important project.

During the coming weeks, staff and physicians at WLMH will help develop detailed plans for the new hospital. Their input will help to ensure that that future health care service delivery needs are translated into the design and construction of the new hospital by providing clinical, technical, operational, programmatic, and equipment information.

Check out our newly released feature sheets to help keep you informed about the road ahead. Find out how new hospitals are financed in Ontario and the government’s process for building new infrastructure.