While healthcare organizations have always faced the challenge of adapting their facilities to evolving services, needs, technology, and healthcare delivery models, the tempo of that change is accelerating.

“It’s virtually impossible for a design that is one snapshot in time to support an ever-changing environment like healthcare,” says Lisa Regan, director of performance and transformation for Bluewater Health of Ontario, Canada. The organization runs two hospitals just across the Michigan border near Lake Erie and recently built a new five-story, 285,000-square-foot facility and renovated an existing five-story, 335,000-square-foot hospital tower. “Keeping up with the rapid pace of change—in terms of technology, new medical practices and procedures, process improvement/Lean initiatives, evolving regulations, and shifting patient demographics—is a real design challenge.”

Adding even more complexity to the mix in the U.S. is the expectation that the Affordable Care Act will drive more non-urgent acute care into ambulatory care settings. “This also implies that the care delivered on the inpatient side of the equation will continue to increase in acuity levels,” says John C. Schrott, president and managing principal architect with IKM (Pittsburgh). “To prepare for that eventuality, providers are looking to create flexibility for their patient units such that the conversion from acute to step down to critical care can be accomplished in the most cost and time effective manner.”

There are a number of ways that healthcare facility design—from infrastructure to interiors—can be approached to make future transitions a bit easier. Granted, there will be more upfront cost required. However, experts say the investment today will better prepare providers for the unknowns of tomorrow.

Starting with structure
To create necessary spatial clearances to support the reassignment of space in the future—and to accommodate the new equipment and clearances that may be required, as well—structural bays, defined as spacing from the center of one structural column to another, has grown from 28 feet to more than 32 feet for new clinical settings. This allows enough space for surgery, imaging, inpatient, or emergency bays, for example, to be sized appropriately now and retrofitted for other uses later without column placement restricting options, explains Curtis Skolnick, managing director of CBRE Healthcare (Richmond, Va.).

For deck heights—as measured from the top of one floor slab to the bottom of the floor slab above—Skolnick recommends 14 feet to 18 feet to allow mechanical, electrical, and plumbing (MEP) and information technology (IT) systems to be appropriately sized for current use and future adaptability.

In urban settings, or smaller sites with limited property space, it’s also important to build with the foundation and structural support systems to allow future vertical expansion, he continues. “By placing mechanical spaces on the roof, they can later function as interstitial spaces for vertical expansion, which will allow for easy tie-in to critical infrastructure in the future.”

Schrott also advises to analyze head-end capacities for MEP equipment, which refers to primary system components such as the chiller and air handling units, to permit changes in space usage without the need to modify the systems in place. This includes stubbing the IT and MEP infrastructure behind the walls so that it can be easily tapped or expanded. In addition, “placing the plumbing chases appropriately, typically on the outboard side or stacked, helps when converting a fit-out room from medical/surgical to intensive care, or vice-versa,” he adds.

Incorporating additional shelled space in an initial build-out should also be considered, to support everything from the addition of elevators to expansion bays for boilers to large mechanical equipment. ”Some shelled spaces can be used for soft functions, such as storage or offices, and repurposed and fit-out later for their intended long-term use,” Skolnick says.

“First cost may be higher, but as things expand, you are going to need the infrastructure to be there,” says Paula Crowley, CEO of Anchor Health Properties (Wilmington, Del.). “The goal is thinking about the future, but not overinvesting to the point where it doesn’t make financial sense.” For example, David Stokes, principal consultant for CBRE Healthcare, says that flexible design comes at a higher premium in terms of large-scale MEP systems and components, and “oversizing” may very well be outside of an organization’s budget. “An option to consider, however, is the modular approach to systems design. By sizing your equipment for your initial loads and leaving pre-planned bays or compartments for future expansion in your central plant, for example, you can save potential costs across numerous phases.”

Layouts and adjacencies
Space planning, especially in inpatient units, can also answer needs for future adaptability and flexibility. For example, centralized staff spaces can expand or contract, as needed, to support transitioning clinical areas. “The most successful design solutions plan soft spaces, like offices, adjacent to capital-intensive departments, such as surgery, imaging, lab, and pharmacy,” says Greg Osecheck, a healthcare principal for HGA Architects and Engineers (Sacramento). As such, the latter “hard spaces” can expand into the surrounding “soft spaces,” as needed.

Locating clinical areas on the perimeter supports easier expansion, too. “Placing clinical zones on the outside walls allows clinical spaces to expand easily on to surface/ground space, onto a roof, or as part of a multistory horizontal expansion, without displacing or impacting an existing functional service,” says Lora Schwartz, principal consultant at CBRE Healthcare.

At the same time, Osechek cautions against land-locking clinical spaces on the interior. “Make sure there is at least one, and preferably two or more, paths of easy expansion into either soft space, exterior space, or shell space,” he says. “For instance, placing the pharmacy in the center of the facility near an elevator core will ensure easy access from the pharmacy to vertical transport, but placing the pharmacy next to the hard elevator core on one side, imaging on the second side, emergency department on the third side, and a major mechanical space on the fourth side leaves no option for the pharmacy to grow or flex over time.”

Sharing a lesson she’s learned, Jennifer Aliber, principal and leading healthcare planner for Shepley Bulfinch (Boston), explains that while elaborate floor plan, such as snowflake-shaped nursing units with the care provider station in the center, may work well initially, they tend to be very difficult to re-plan over time. With an eye on the future, the industry is trending back to old-school hospital design where spaces are set up in a rectilinear fashion, thereby making future renovations and additions much more straightforward.

Easy reconfiguration
The need for future adaptability is also driving the growing use of reconfigurable casework and demountable walls in healthcare spaces. For example, for the 285,000-square-foot consolidation of two facilities and 335,000-square-foot renovation of an existing facility at Bluewater Health, reconfigurable
casework—in place of fixed millwork—was selected for more than 80 percent of the fit-out. In addition, more than 6,000 linear feet of demountable walls now stand in place of steel-stud and gypsum-board walls.

Not only did Bluewater pick up 11 percent in first cost savings by choosing this casework, but when it was time to reconfigure some of those spaces a year later, the savings jumped to 74 percent.

For two current Mercy Health projects in the Cincinnati area—Anderson Hospital and The Jewish Hospital—demountable wall systems were selected for technology zones on patient room headwalls and footwalls, a move Mic Johnson, Architecture Field Office design principal, says allows an easy change or addition of technology.

Another popular interiors solution is modular casegoods, such as interchangeable wall-mounted storage, work surfaces, wardrobes, drawers, glove and paper towel cabinets, and sinks. “All components are mounted on a rail system, allowing product to be easily reconfigured and reused in other locations,” says Anne Garrity, associate and senior interior designer for Shepley Bulfinch. “Additional components, such as mobile linen carts, rotating work surfaces, and marker boards complete the assembly for most applications.”

Change is inevitable
Incorporating flexibility and adaptability into today’s healthcare facility designs—with an eye on the future—is critical.

“Hospitals are looking for ways to align workspaces with continuous improvement in work processes, and for solutions that mitigate the risk of obsolescence and promote the ability to adapt, quickly and cost-effectively,” Regan says. “In circumstances where change is a constant, the best investment a healthcare organization can make is in a facility that can—and will—change.”

Barbara Horwitz-Bennett is a contributing editor for Healthcare Design. She can be reached at bbennett@bezeqint.net.