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‘Rigor and Research in Healthcare Design: A Decade of Advocacy:’ Flexibility, Differential Obsolescence, and Measurement

The McMorrow Reports is pleased to share with you the final excerpt from the industry-acclaimed Evidence-Based Design resource book Rigor and Research in Healthcare Design: A Decade of Advocacy.

The book was written by Kirk Hamilton, FAIA, FACHA. Hamilton is a Professor of Architecture, Texas A&M University, a Founding Principal of WHR Architects and a board member of The Center for Health Design. He is also an editor of Health Environments Research & Design Journal. Hamilton has published more than 30 articles, many of which are featured in the book, on Evidence-Based Design (EBD) in HERD and Healthcare Design magazine.

Herman Miller Healthcare, working in collaboration with Hamilton and Vendome Group compiled many of the architect’s writings into this single, printed publication.

Excerpted from Chapter 15: “Flexibility, Differential Obsolescence, and Measurement.”

“Because the future is unknown and largely unpredictable, healthcare organizations and their design professionals might be advised to consider alternate scenarios for the future. Peter Schwartz (1991) has proposed a thoughtful model in which organizations consider multiple alternate futures. The principal plan moves toward the most predictable future, but other contingency plans are developed for plausible alternative futures whose appearance would have a major impact on the organization. These alternate future scenarios include the identification of “trigger” events that would indicate that an alternate scenario is occurring. When a trigger occurs, the organization has already planned a response for this new situation. This kind of scenario planning might be seen as flexibility in planning. …

Just as there are many types of strategy, there are, of course, many different types of facility change. There must, therefore, be many ways of understanding these differences, which suggests that one form of response may not be sufficient to address an issue. There are multiple types of flexibility to address each different form of  possible change.

Scale of Change
Change can occur on many different scales, and at times it may be simultaneously occurring on more than one scale. Change can happen on the scale of a single room, a unit or department, an entire building, a campus, or within a system that has multiple sites.

Pace of Change
The Institute for Healthcare Improvement works with rapid-cycle change, which often moves at a pace that is less likely or possible for facility change. At the other extreme, major hospital projects costing multiple hundreds of millions of dollars can take more than a year to design and another three or more to construct. In many parts of the world, however, this would be considered swift because of the glacial pace of regulatory and government funding processes. …

Flexibility and Types of Change

The simplest type of facility change is alteration, when an aspect of a facility is capable of being altered for another function. I consider adaptable flexibility to mean that the space in question is suited to multiple uses or can be quickly and inexpensively adapted simply by changing the room name and furniture. Convertible flexibility describes spaces that can house a new function through simple, low-cost conversion or simple changes in technology.

The flexibility of standardization refers to spaces that are sized to accommodate several possible uses and the availability of utilities for many possible types of use. An example of this kind of flexibility would include a decision to enlarge a room that needs to be 80 square feet because a room of 120 square feet
could serve many more possible future uses. Change that requires renovation caused by organizational reassignments includes simple physical changes at moderate cost. Major renovation involves more costly physical changes that include plumbing, air handling systems, and other complex building elements. Flexibility in renovation depends on advance planning for building systems that can be altered with less difficulty. Another sort of facility change is reactive. Organizations may be obligated to renovate to bring buildings into compliance with code, or to perform maintenance, as required by updated regulations.

One strategy allows for wide variation in response to the future. Construction of shell space offers a completed external building shell within which the future function can later be constructed. The blank slate of shell space can be planned later to address whatever need has arisen. On the other hand, some designs are totally customized and unalterable, offering no flexibility. An example of such a unique design, tailored for a specific function, is a facility housing proton therapy equipment.

An anticipatory strategy for flexibility addresses future capacity. Some designs seek to offer a simple “plug-in” ability to insert new functions and rapidly connect to existing utilities. The design of a structural grid that features wider spacing between columns can be a strategy for flexibility. Design to accommodate unusually high floor loading capacity, as in the case of heavy magnets or film files, can offer flexibility. Structural capacity for vertical expansion is another way to prepare for a particular kind of future. The installation of a robust utility network, with extra capacity for water, power, sewer, telecommunications, information systems, and fiberoptic networks, can lessen the complications of change. Portions of a complex hospital might be designed as a flexible technical warehouse, featuring long structural spans, generous ceiling heights, a robust utility distribution network, the ability to serve multiple functions, and the ability to be changed on an economical basis.

A final type of facility change is additive. This involves an addition in the form of new construction on adjacent land or vertical expansion, or it can describe replacement in the form of new construction to replace obsolete facilities. It is often possible to anticipate where such buildings might be located, and to consider their future use when planning site utility locations, roads, landscape plantings, and when reserving sites for future uses. …

 Measuring Flexibility
If one can measure levels of flexibility, it ought to be possible to plan more effectively for the implementation of designs intended to provide specific accommodations for particular types of change. Analysis, measurement, and evaluation of flexibility ought to make it more feasible to have confidence in important design decisions. One method for such an analysis might include clearly establishing what sort of change is being addressed. For each particular type of flexibility that targets a particular type of change, it might be useful to examine its relationship to current and future function, cost, and time parameters….

It might be possible to use a five-point scale, similar to a Likert scale, to evaluate flexibility strategies within any given category. The five points might be described as (5) high flexibility, (4) above-average flexibility, (3) average flexibility, (2) below average flexibility, and (1) no flexibility. The advantage of such a system is the ability to convert a subjective opinion into a quantifiable response. …”

“Rigor and Research in Healthcare Design: A Decade of Advocacy” is available for healthcare leaders, architecture and design professionals, as well as college students enrolled in healthcare design programs only through Herman Miller. You can request a copy of the book by contacting Anne Parks via email: anne_parks@hermanmiller.com