Identical air handling units are manifolded together to provide redundancy, flexibility and future capacity at the University of Minnesota Masonic Children’s Hospital.

When the design professionals at Hammel, Green and Abrahamson (HGA) were contemplating the infrastructure needs of the University of Minnesota Masonic Children’s Hospital during a renovation earlier this decade, they did not just think about the facility’s immediate needs. They also looked years into the future.

“The existing plant was from the 1890s, and we had to take a large step back to make sure the mechanical and electrical systems would work for today and for future expansion,” says Krista McDonald Biason, PE, associate vice president of HGA.

Planning for potential future needs, such as HGA did with Masonic Children’s, is becoming increasingly critical in today’s changing health care environment.

“Money is scarce today, so the discussion of flexibility is becoming more important,” says Jeff Harris, PE, director of mechanical engineering for HGA. “Hospitals want to get more bang for the dollar.”

Changing landscape

The changing nature of health care reimbursement, a growing senior population and general trends in health care all are driving the need for more flexible facilities. Designs that make sense today may not fulfill an organization’s needs in a decade.

“Health care is in a huge state of change, obviously from pressures created by the Affordable Care Act. But other demographic, sociological and technological trends are also disrupting the view of what health care is,” says Arthur Kjos, AIA, NCARB, FASHE, executive director of facilities planning, University of Arkansas for Medical Sciences. “Patient services that have traditionally been the purview of acute care hospitals are rapidly moving down the chain to clinics and to the home. We cannot predict where this will all end, but certainly it will not be what we are doing now.”

It is that unpredictability that is driving health care organizations to be flexible, because it does not make sense to spend $100 million on a building that may be made obsolete by changing conditions. And with reimbursement changing in ways that are not yet fully realized, organizations fear that today’s investment may become a liability under a different payment structure.

Location and beyond

The design of a flexible health care facility typically does not begin on the drawing board. Often it begins before a physical location is even determined.

For example, many patient services are moving from central hospitals to dispersed neighborhood locations. Since neighborhoods change and populations expand in various directions, a flexible location can serve a health care organization well. Jason Busby, a senior manager at Kurt Salmon, calls this the Wal-Mart strategy — always being ready to move when the market moves.

“As populations shift over time, it may make sense to continually move your facility to where the population is going to be,” Busby says.

An important element in space flexibility is deciding whether it’s smarter to lease or buy. Naturally, that decision often comes down to the use of the facility. It’s easier to find a space to lease if an organization is opening a clinic, for example, than if it’s opening a new tertiary care center.

“A primary care clinic is not substantially different from a regular office building,” Busby says. “So why build something new if you can find something less expensive to lease?”

Being flexible regarding location is just one early step. Another is taking on a flexible mindset about the overall project design.

Annie Coull, AIA, ACHA, EDAC, vice president of Stantec, notes that when her firm was developing a new hospital and ambulatory campus for the University of California San Francisco (UCSF), flexibility was identified as a goal at the beginning.

“Flexibility is one of the project’s guiding principles — ‘promote healing, new approaches to care and innovation through the adaptive use of space and staff practice,’ ” Coull says.

What exactly flexibility means is up to the client. “The key is to define up front the type of flexibility aspirations held by the client,” she says. “The range may be daily occupancy changes to long-term change of space use. [The designer also should consider] the organization’s cultural response to change — people’s comfort with change in behavior to accommodate flexibility inherent in space.”

About this series

This series of tutorial articles is a joint project of the American Society for Healthcare Engineering and Health Facilities Management.

The design process

Knowing early on that flexibility is a key desired characteristic changes how plans are made. The designer no longer can be satisfied with envisioning the project on the day the doors open — he or she must be able to imagine the next use for that structure, and the use after that.

Jack Poindexter, a project executive at DPR Construction in Redwood City, Calif., says that an essential part of flexible design is building a design team with that concept at heart.

“A major challenge is to train the project team to appreciate that health care equipment and practices are constantly changing,” Poindexter says. “It takes seven to eight years to design and build a major hospital in California, thus major aspects of the owner’s initial program and equipment can change. In recognition, the owner, architect and contractor have to build a team responsive to accommodating change.”

When designing for flexibility, several strategies should be considered. They include:

A building block approach. When HGA was designing the Masonic Children’s Hospital, it used a “building block” approach to create a flexible space. Systems were designed and built in a fashion that easily would accommodate expansion as needed. Designers adopted a “modular” mentality, which meant they incorporated a greater number of smaller, standard-sized units rather than fewer, larger units.

“For example, you’re better off to buy four or five 500,000-Btu boilers than one 2 million-Btu boiler and be ready to add more as needed,” explains Harris, of HGA. “You only buy what you need now, but you build in the ability to wheel in more later.”

In the Masonic Children’s Hospital project, for example, the electrical distribution equipment was entirely replaced, and an additional switch was added to accommodate a building that did not yet exist, but which is part of the campus’ long-range master plan.

“The flexibility is there if that occurs,” McDonald Biason says.

Kjos was involved in the repurposing of two “big box” stores into health care facilities when he was a principal at Clark/Kjos Architects, and those facilities also included some elements that allow for potential future expansion. For example, an 80,000-square-foot building that previously housed a Kmart was repurposed into a wellness center with space for a gym, physical therapy, urgent care and other services, but the facility was designed so that more services could be added if demand warranted.

“The primary life safety systems were upgraded to a higher standard to allow for various levels of health care to be included,” Kjos explains.

Soft space adjacent to hard space. It is much easier to expand an emergency department or imaging department if the space next door is “soft,” such as a storage room or office. Taking that fact into account during planning makes the eventual expansion much easier.

That’s what designers of the new hospital and ambulatory campus for UCSF did, Poindexter says.

“Designing soft spaces next to areas that will expand enables future growth while maintaining critical adjacencies,” Poindexter says.

The addition of soft space beside hard space is not always easy, however. Harris notes that one of the principles of Lean thinking is the reduction of steps between work areas, so if Lean principles are deemed more important than flexibility, it’s unlikely a designer will add a storage room between an operating suite and a recovery room.

“Architects have to take all those criteria into account,” Harris says.

Another way to arrange spaces to allow for future construction is to make sure the mechanical spaces are located along an exterior wall. “That way the wall can get blasted out and new space added,” Harris says.

Standardized, multiuse rooms. Many new health care facilities are designed with standardized rooms that can be used for multiple purposes as the need arises. For example, if the infrastructure is in place, a regular patient room could be upgraded to an intensive care space later or, conversely, downgraded to office or storage space.

The same goes for small exam rooms or procedure spaces. If designed well, their purpose easily can be shifted as needed.

“A facility that wants flexibility needs a room type that is flexible enough to ebb and flow when the need changes,” McDonald Biason says.

Standardized construction also can save money, since building numerous identical spaces is more efficient than building numerous customized, unique spaces.

At what cost?

No discussion of flexibility occurs without a discussion about cost. Adding future capacity is not free and, in these uncertain times, every dollar is closely watched.

“The idea of universal, modular designs seems really good, but an issue we’re starting to see is facilities that want to build rooms all to an intensive care-level capacity when they can’t predict what will happen three to five years from now,” Kurt Salmon’s Busby says. “In the future, we may see that as wasting resources because they were overbuilding capacity.”

David Chamberlain, also a senior manager at Kurt Salmon, notes that as reimbursement changes from a volume-based model to a more value-based system focused on population health, health care facility space no longer can be considered in the same light.

“Conventional thinking has been to build to the highest common denominator, but we really can’t afford to take that approach across the board anymore because space is a fixed cost rather than a revenue generator,” Chamberlain says.

On the other hand, the concept of flexibility is intended to save money in the long run. McDonald Biason says HGA is working on a wing addition to a building that is only 14 years old but does not have the infrastructure to handle additional capacity. Consequently, much more expensive work needs to be done now than would have been the case had a little more money been invested when the building originally was constructed.

“There are a lot of buildings that just wanted to put in the amount of money needed for the moment. If this building we’re working on had just upsized up front, it would have been a better solution,” she says.

Harris says the additional elements being added to the central plant in the Masonic Children’s Hospital project are adding 3–5 percent to the cost of the plant. Since the central plant represents about a quarter of the total cost of the project, those flexibility additions add up to about 1 percent more in overall costs.

“I think people intellectually understand the need for adding these things, but it does come down to cost,” Harris says. “We try to provide things for an incremental increase in cost now to get more value later on. But there is a finite amount of resources.”

‘Things will change’

A flexible, adaptable health care facility is designed to accommodate changing needs. It follows, then, that the process for designing such a facility is not one-size-fits-all. Every project stands on its own, and the process for getting to a flexible final facility varies.

“Each organization is different, so it’s hard to take a universal solution and apply it to so many places,” Busby says. “Things will change. I guarantee that.” 

Ed Avis is a freelance writer based in Oak Park, Ill., who was contracted by the American Society for Healthcare Engineering to write this article.

Learning more about flexibility

Want to learn more about flexible facilities? The 2015 International Summit & Exhibition on Health Facility Planning, Design & Construction, which will be next month in San Antonio, is focused on innovative ways to adapt to an uncertain future. Several sessions are directly related to flexible design and construction, including:

• “A New Way Definition of Flexibility for Tomorrow's Health Care Environment”

• “Retain Market Share: Repurposing Today's Built Environment for Tomorrow's Health Care”

• “Meet the Goal: Flexing with Change Without Sacrificing the Plan”

• “Seattle Children's Building Hope: Delivering a Flexible Design Using Lean Planning”

• “Collaborative Innovation for Future-Proofing: Outcomes and Lessons Learned”

• “Engineering a Flexible Health Care Facility One Building Block at a Time”

• “Transforming a Health System to Support Population Health and Community”

• “Flexible Design Solutions: Aspirations and Results in an Academic Medical Center Replacement Project”

Registration for the PDC Summit is now open at