Shannon Kraus, FAIA, FACHA, principal and senior vice president of HKS
Photo courtesy of HKS

The transition to population health and community-based care is causing designers to rethink how new and existing facilities can better serve patients, as award-winning architect Shannon Kraus, FAIA, FACHA, principal and senior vice president of HKS, explains.

How is the increased emphasis on community-based care affecting the design of new health care facilities?

The transition to community-based care and population health is causing owners and health care systems to take stock of new projects and, in many cases, shift or put on hold what they were planning to do. We know hospitals that were planning to build greenfield replacement hospitals that now are re-evaluating that.

They’re thinking of building urgent care facilities and bedless hospitals and bridging solutions that may serve community needs in a more right-sized scale and in a manner that gives them greater flexibility for the future as this uncertain health environment sorts itself out.

The big driver is placing outpatient care back into the community and minimizing the number of patients who go to the acute care facility campus. On a central campus, there are more renovations and additions, and targeted renovations to right-size the acute care facilities for a more targeted service line.

Plus, we’re seeing more partnerships emerge. It’s no longer just health systems operating alone, especially because of population health and pressures on revenue.

There is new openness to working with developers and with government agencies to offer services that might help health care facilities and share the risk and financing to deliver more value to communities.

Does that make your job as designer more complex?

It’s made the task of delivering right-sized, optimized facilities more complicated because more flexibility in a higher-risk environment is essential.

There also can be more stakeholders involved in public/private partnerships to deliver more value to patients through health-focused initiatives. As an example, we’ve got one client where we probably have no fewer than 30 stakeholder partners that are going to contribute funding toward the rebirth of a health care facility. They all want a say in their piece of the project.

The partnerships are good for mitigating financial risk with the providers, they are good for the community and good for the patients.

What will happen to existing facilities, especially the acute care hospitals that were built during the last five to 10 years?

They will become more acute and more specialized. Most of the facilities built within the past five years are relevant to what they’ve been doing, but much of the outpatient care service will be decanted.

We will see a rise in boomers moving through the health care system. We’re going to see an increased demand for health care in general, but a higher percentage will be treated off campus.

The net result is that we don’t think there will be growth or shrinkage on the acute care campuses, but there will be repositioning on the acute care campus of more specialized services. All this is to keep people healthy and out of the hospital through an increased focus on chronic disease management, healthful living and post-acute care.

What is the future of aging health care facilities?

Providers are looking at getting more for their dollar by building newer facilities that might be smaller than what they have today, while not necessarily walking away from historic community connections.

The old building might be a renew-in-place or sometimes it means building a new bed tower adjacent to the building or renovating the older hospital for administration or other uses to keep a community connection.

If it’s anchored in the heart of the community and depending on the age of the facility, it might have more value as land given back to the community for development, which increases the tax base. Some older facilities may be used for community programs, education and health awareness.

In most cases, we work with health providers to partner with communities to determine together what is the best solution for older infrastructure, particularly if replacement facilities were built.

What’s the next big innovation in technology that will impact design?

An area in which technology is going to come into play in health care is the use of big data. We’re starting to see health care groups building their own data centers.

Like retail businesses, health care will look beyond patients’ ZIP codes, where they came from and what illnesses they have. Providers will use data to identify a population segment that, for example, buys a lot more sugary soft drinks and has a greater number of diabetes cases.

Through electronic health records you can mine data in a way that you stop trying to be all services to all people. A provider opens a storefront where it can locate targeted interventions — wellness programs, preventive medicine, health education — into population pockets that are having a higher incidence of particular issues.

Most health care researchers will tell you that 10 percent of the population drives 80 percent of the health care costs. If you can target and treat that 10 percent on a preventive level, then you need less specialized resources for the remaining population. The best way you can target that 10 percent is with technology and data.

What does it mean for designers?

Greater risk for our clients requires greater flexibility and growth scenarios for solutions. Even though acute care campuses might become more specialized, those specializations will evolve with time.

We need to understand what might drive the marketplace and help clients rationalize their offerings to better serve patients, whether they are storefront clinics or acute care campus facilities.

We have to understand the strategic priorities of a system and its market, and work with clients to shape a facility that supports multiple eventualities. These are big-dollar investments by clients who want to minimize risk, and we can do that with innovation. To this end, we need to have better command of the impact our facilities can have on driving value to the patient. Lean and integrated project delivery are tools to do that.

How does design help to achieve higher patient satisfaction scores?

Human interactions and responses to satisfaction are driven more by emotion than fact or logic. The hospitality industry learned long ago that you can have the best facility in the world, but if the staff treat you like a number or machine to be processed or if you have negative memories, because those human interactions are emotional, the satisfaction scores will reflect that.

We need to focus on the idea of touch points, interaction between caregivers and patients that are key to patient satisfaction. I believe facilities can be a positive or negative reinforcement toward that.

Facilities that offer intuitive wayfinding, are easy to navigate, have more natural light, have in general a more healthful environment in which to work and also to be cared for can affect staff and patient attitudes.

Both the caregiver and the patient can come into that interaction from a positive standpoint and the satisfaction scores reflect that. Facilities definitely have a role, but it’s all about navigating those touch points.

If the facilities are dark and dreary and unhealthful or make staff more likely to be stressed or tired, it will be more difficult for them to have a positive interaction with patients.

Is sustainability still a priority for health care providers?

Sustainability is a key factor in driving a healthier population. It is the right thing to do and is moving from buzzword to core and basic practice.

So, yes, this is a priority for care providers and the commitments they make to their staff and patients. But that doesn’t necessarily mean they want to build facilities to the level of being Leadership in Energy and Environmental Design (LEED)-certified.

What’s next for sustainability?

Sustainability is becoming less about LEED certification and more about health and resiliency. The next tier includes helping providers to become more resilient, and may also include greater attention on carbon neutrality.

However, to get there will definitely require new types of partnerships with communities, as both resiliency and carbon neutrality matter most on a community level. 

is senior editor of Health Facilities Management.

The Kraus File


Principal, senior vice president and managing director, Washington, D.C., office, HKS


• University of Illinois, master of architecture and master of business administration

• Southern Illinois University, bachelor of science in architecture


• His projects have been honored with design awards from the American Institute of Architects (AIA) and by numerous publications covering the health care facility design industry.

• He was awarded Young Architect of the Year by the AIA in 2005 and by the Texas Society of Architects in 2006.

• In 2005, he served as national vice president on the AIA board of directors, where he helped to organize and lead its knowledge and research agenda.

• In 2007, he founded the HKS design fellowship to bring together designers from across the globe to focus on community-based design.

• He is a contributing author to the Facility Guidelines Institute 2014 and 2010 Guidelines.