Healthcare projects today, whether they’re inpatient or outpatient settings, are fueled by client goals of achieving flexibility and reduced cost. In the design and construction world, the latest trend to answer those combined needs isn’t new at all—rather, it’s a new application of an old solution: prefabricated wall systems.

Also described as “modular” or “manufactured,” these wall systems comprise standardized components that are fabricated in a factory and shipped to a project site to be assembled into desired room and space configurations. Flexibility and interchangeability were two of the key characteristics that made them popular for decades in office settings and a worthwhile alternative to hard construction installations, allowing easy reconfiguration of space when needed. However, it wasn’t until recently that manufacturers adapted the products in a way that made them suitable for healthcare environments. Specifically, improvements to acoustic performance, ability to support medical devices, and standardized sizes corresponding to medical facilities were accommodated to make the products more desirable for use.

These changes have coincided with the industry’s need to adapt to evolving provider and patient bases, types of care being offered, and new technologies. While early healthcare facility designs were less focused on such features as standardization and flexibility, as clinics and hospitals were more rigid in their designs and rarely allowed for changes or the construction costs they involved, today’s owners and designers are seeking adaptive design solutions and beginning to consider prefab as a viable option.

Three recent healthcare projects where modular systems were introduced serve as examples of the applicability of this solution in various settings:
• Puyallup Tribal Health Authority Ambulatory Clinic—In the early 1990s, the Puyallup Tribal Health Authority (PTHA) built a 30,000-square-foot ambulatory health center in Puyallup, Wash. At that time, traditional hard wall construction assemblies were used. Twelve years later, when it was time to both upgrade and expand the facility to accommodate new patient needs and support an onstage/offstage care delivery model, PTHA chose to overhaul the existing clinical spaces and redesign the interior using a modular wall system, as well as add 10,000 square feet of new clinical space using the same modular wall concept. The goal was to provide flexibility to adapt to future health delivery concepts without having to fully remodel the building again.
• The Polyclinic Northgate Plaza—In 2016, The Polyclinic (TPC) in Seattle began developing clinic space in an existing five-story, 60,000-square-foot building. The intent was to establish provider space one floor at a time and expand over multiple years. The provider didn’t own all the floors yet and decided to use a modular approach that could be adapted to each floor as it became available. The challenge was creating flexible exam room modules that could be modified at any given time, without disturbing tenants above or below. To that end, TPC used prefabricated wall systems for the initial 12,000 square feet of development on the second floor.
• EvergreenHealth Silver Tower—Evergreen Hospital’s Silver Tower was designed and constructed in the mid-2000s and included multiple vacant floors for future development. In 2015, the provider was ready to finish two floors of progressive care units totaling 62 beds, but also recognized that there would be complications any time technology or utility services had to be upgraded, likely resulting in patient rooms temporarily being shut down and hospital revenue affected. The provider decided an innovative approach was required and requested the use of prefabricated walls for any location that didn’t require fire- or smoke-rated assemblies, including headwalls and footwalls.

Key drivers
The author toured each of these buildings with their respective facilities director or staff members, interviewing the users about key decisions that helped them determine the use of prefabricated walls as the building delivery solution. Seeing more demands for these types of applications in healthcare facilities, the goal was to learn the driving forces behind the decisions to use these systems.

Among the top reasons was the ability to establish standardized care spaces and layouts to simplify assigning practices to any portion of the building and making future changes easier. Facilities teams often have ideals of establishing standardized room sizes throughout a building. However, reality often dictates the use of many one-off rooms that don’t meet that standard, resulting from column spacing and placement of stairs, elevators, and mechanical/electrical rooms.

The facilities teams were determined to establish standardized care spaces and found that working within the manufacturers’ modular systems helped them achieve that goal by taking the first step to define functional uses in allocated spaces. For example, if an exam room is planned for 10 feet by 12 feet, the wall system modules must support the dimensional needs of this configuration. This offers the future ability of changing the configuration of the modules into smaller or larger rooms using standardized panel widths. While the facilities may not have achieved 100 percent of their standardization goals, all were in the 90th percentile.

Another driving factor was adaptability. One month, a physician’s suite may be dedicated to primary care and the next month to pediatric care. A medical/surgical patient room may become an ICU patient room next year, as service demands change. Facilities that are flexible and modular have the greatest advantage of allowing these adjustments. Keeping the walls where they exist and removing the face panel from the wall to access the framing system allows for low-voltage wiring, power outlet configurations, nurse call devices, and even plumbing to be installed, modified, or removed without tearing down walls. The facilities directors surveyed noted this has huge cost-savings potential in reducing the days a room is inoperable to only 10-20 percent of the normal remodel schedule.

Lessons learned
Now that these facilities have been operational for a few years, valuable feedback was offered from the staff concerning challenges in implementation, cost impact, and overall satisfaction. For starters, many agreed that completing the projects was difficult in ways not expected. Working with designers, planners, and builders who hadn’t previously applied modular systems to projects was more difficult than anticipated. The design efforts required more intensive and interactive processes between the various design disciplines and the product technical representatives regarding capacities and connections. In some cases, rethinking the sequence of activities from design through construction was required, as it related to which project components needed to be installed prior to others. While the overall project schedule didn’t change, the timing of some activities had to be rearranged to either earlier or later than traditional construction to make the interface happen correctly.

Project delivery was at times confrontational, too, as more components had to be delivered simultaneously, thus competing for on-site storage space. Owners, designers, and builders initially didn’t realize using component systems could mean the entire wall assembly shows up at the project site at one time and needs to be stored until installed. With many of these projects being build-outs of shell spaces or remodels of existing spaces, available storage space was at a premium or nearly nonexistent. Overall, those interviewed said project teams would be well-advised to consider designers and builders who have completed similar projects and understand such intricacies of communication and coordination.

In terms of cost, none of the owners expected to save time or money with their first use of modular systems, but they do anticipate long-term benefits in reduced costs when spaces need to be reconfigured. First costs for these projects may need to increase to accommodate the modular components (they are more expensive than traditional construction), but long-term costs are reduced when considering future changes and remodeling that may occur.

Although there were no expectations for a shorter project schedule—nor were they shortened—if the same team members were to engage in a similar project in the future, it’s expected that the process could be streamlined due to team members who are better educated and more familiar with the design and construction of these systems. All three of the facilities staffs said they would use the modular system again, and, in fact, two are already using the systems as they continue to build additional floors in their facilities.

Designing for flexibility in healthcare is a necessity. Design and building professionals must understand how facility costs impact everyone’s bottom line and work together to implement solutions like modular systems that support streamlined and ongoing facilities projects.

Dale A. Anderson, AIA, NCARB, LEED AP BD+C, CSBA, EDAC, MBA, GGP, is principal at Salus Architecture Inc. (Seattle). He can be reached at dale.anderson@salus.archi.