Two weeks ago, my colleague Simon Bruce touched off a discussion about using Lean principles in planning and design. A current strategy of Lean design is to get as much program as possible out of the expensive I-Occupancy construction and into an adjacent B-Occupancy building (i.e., a glorified MOB). In the abstract, with construction costs going through the roof this would seem like a no-brainer. For example, Simon has reduced the I-Occupancy space-per-bed by approximately 25% for one of our academic medical center clients through this approach—which could ultimately result in big capital cost savings for the client. But Simon and I have found there may be concrete issues that challenge the long-term wisdom of this trend.

First, some of the cost savings may be sacrificed if a client wants the B-Occupancy space to act as a contiguous part of the hospital environment. For instance, to align floors between the two buildings the floor-to-floor heights will be higher for a hospital-adjacent, B-Occupancy structure than for a standalone MOB. Another issue is seismic design: a standalone MOB obviously has fewer regulations for seismic resistance than an acute care hospital. But when that same MOB is standing immediately adjacent to the hospital, it becomes a collapse/impact hazard and must be designed with that in mind. The point? The cost of a standalone MOB is not an apples-to-apples cost equivalent to a hospital-adjacent B-Occupancy building.

A second issue concerns acute-care expansion. When so much of the soft functions are decanted into the B-Occupancy building, there is less wiggle room for in-place expansion within the hospital. I-Occupancy space can always be changed to B-Occupancy, but not the other way around. This leads to a third issue: flexibility. We have seen how easily a B-Occupancy building can become a planning tombstone on a campus. Acute-care egress cannot pass through it, essential hospital services and infrastructure must avoid it, and it is often physically entwined with the functions that most need room to grow. Yet at the same time, the B-Occupancy space often wants to be the front door of a hospital, because of the code allowances for two-story lobby spaces and because many of the typical front door services are also good candidates for B-Occupancy space.

What most encourages this B-Occupancy trend is the limited planning window imposed on a typical facilities administrator. The administrator is the one that must deal with fundraising challenges and pressure from the board to reduce building costs as much as possible. The benefits of long-term efficiency, on the other hand, will usually be reaped by his/her successors. This trend isn’t going away any time soon, but I think that, as healthcare architects and planners, we need to make our clients aware of the long-term costs of this enticing quick fix.

Eric Meub, AIA, is vice president and design principal at SmithGroup, a leading healthcare architecture and engineering firm with 10 offices across the U.S.