This three-part series explores the topic of flexibility in architecture. The first article examined the main reason for flexibility: change. The second article explored the three types of flexibility (convertibility, adaptability, and transformability) and how they can be beneficial to the healthcare field. This third and final article studies incorporating flexibility into the design process, along with specific architectural flexibility strategies.

Hospital facilities are always changing. Without leadership, a clear vision, and guiding principles that specifically target flexibility, healthcare facilities can become oversized and develop inefficient circulation and complex wayfinding. A holistic, facility-wide approach to flexibility will create a cohesive campus, and reduce costs and downtime during future construction projects, as well as lengthen building lifespans.

Although the specific ways in which a facility will evolve can’t be predicted, there are some basic assumptions that can help a design team prepare a hospital for future growth and expansion.

In this article, architectural strategies for flexibility are presented at two scales: micro and macro. At a micro level, the strategies operate within circulation approaches, zoning, and programming. At a macro level, the strategies affect site placement, building shape and orientation, and vertical and horizontal expansion considerations.


Micro approaches
For buildings that are planned with the potential for horizontal growth, the inclusion of open-ended hallways facilitates future expansion. Instead of the traditional approach of placing programmed space at the end of a hallway, open-ended hallways extend to the building’s façade.

This approach reduces overall circulation efficiency and is a little more expensive than regular corridors, because space that otherwise would be revenue-producing becomes circulation.

However, when horizontal expansion is needed, the new circulation can connect directly to the existing circulation, and interior demolition work is reduced because no programmed space prevents the connection.

The identification of “hard” and “soft” spaces and their strategic placement within a healthcare facility’s layout is a simple method to provide flexibility. “Hard” spaces are difficult to move and expensive to build; “soft” spaces can be relocated relatively easily and are comparatively low in cost.

This method of zoning adequately accommodates future growth while maintaining critical adjacencies. In addition, investments for relocation and renovation projects are lower than costs for new construction. However, the spaces that are relocated can lose critical connections to other areas and functions, and its operations are severely disrupted while relocating.

Other design elements that need to be considered for this strategy to be effective are mechanical systems, walls, and structure. These need to be compatible with both the start state and end state.

A healthcare facility increasing operating room capacity by adding an additional suite will do so more easily if the ORs are next to an easily moved function. The same task might be considerably more complex if the OR area cannot grow in an adjacent direction, or would have to relocate more expensive services, such as imaging.

The inclusion of soft boundaries can also help a facility in terms of flexibility. Locating like-type programs near each other provides the opportunity for shared spaces, especially if hard boundaries are eliminated.

For example, locating clinics with similar programmatic requirements in an adjacent manner allows them to share spaces, and enables the clinics to grow or shrink as patient volume changes. Potential challenges with this strategy include code and regulation limitations that might prevent sharing support spaces.

Shell spaces
Incorporating shell space into a design is beneficial because it can accommodate new functions while maintaining existing adjacencies. Once the need for a new function is identified, the space can be built out to the requirements of the new program, and benefit from adjacencies that might not be possible if the new function were accommodated by expansion or new construction.

The amount, size, and location of shell spaces need to be carefully considered, since they are not revenue-producing spaces and often are regulated by state and local authorities.

Multi-use spaces
Providing space that can accommodate a variety of programs is also a valuable strategy when thinking about flexibility. Multi-use spaces include classrooms and conference rooms, consult rooms that can be used for non-clinical patient visits, and universal rooms. Universal rooms combine the requirements of regular inpatient rooms and intensive care rooms, allowing a facility to increase occupancy rates while reducing space requirements.

They also reduce patient transfers, saving staff time and reducing staff costs. However, there are hurdles to overcome when incorporating universal rooms; among them, the increased training needed for nursing staff, as well as a change in organizational culture.


Macro approaches
Site placement
Site situation and building massing require a project-specific approach, although many sites may be approached similarly. For instance, the empty chair strategy embraces a cycle of building obsolescence with the assumption that the facility will be demolished in a certain number of years.

The original structure is constructed on no more than half of the site, leaving room for future building projects. Once the new construction occurs on the vacant portion of site—without interruption to the existing hospital operations—the old building is demolished, leaving half of the site available once again for future construction.

This strategy is restricted to sites large enough to accommodate two buildings; it’s not feasible in small sites. Additionally, it writes off facilities that could be remodeled to suit current needs.

Planned expansion
Another strategy is to design the building with planned expansion paths for the future. Many facilities opt for this approach because it provides for several levels of change. A facility might opt to build out all the portions of planned expansion or only the pieces that will accommodate their current facility needs.

For types of facilities where sites are unconstrained and horizontal expansion is the future expectation, a master plan—either detailed or diagrammatic—can be extremely useful. Blocking out possible expansion routes in the beginning of the design phase helps develop a coherent design.

In terms of structure, a regular grid has proven to be more flexible in renovating existing projects. Regular grids are more cost-effective and introduce standardization into the facility planning.

Vertical expansion of structural systems also plays a role in macro-level strategies of flexibility for hospitals on a constrained site. The ability to construct additional floors at an undetermined time in the future has proven to be effective because the initial capital investment is much less than the future cost that would be incurred due to an inability to expand.

In this case, appropriate steps would be to design additional capacity into the structural system and prepare the roof for incoming column connections, as well as a
voiding locating mechanical equipment on the roof.

In addition to a structural over-design, a facility can benefit from a forward-looking circulation strategy.

The Northeast Georgia Medical Center in Gainesville, Ga., designed by HKS, Inc., operates with two public elevators in its patient tower. However, three elevator shafts originally were built. The third was sealed, with the intent to install an additional elevator when the patient volume required it, or when additional patient tower floors were built.

Northeast Georgia Medical Center also incorporates other vertical and horizontal expansion strategies.

Interstitial floor
The inclusion of interstitial floors requires the hospital leadership’s firm commitment to flexibility, and the understanding that a lower construction first cost may not be as beneficial to the facility as increased flexibility.

Because wiring, ducts, and other services are located on an interstitial floor, the floors it services are better able to be reconfigured without the restrictions of mechanical services. In addition, routine and emergency maintenance can be performed without interrupting regular operations, since access is on the interstitial floor and not through acoustical panels on the ceiling.

Including multiple strategies will render different results for each project. For example, WellStar Health System and CDH Partners exhibited their commitment to flexibility by incorporating multiple strategies in the design of the Paulding Replacement Hospital.

Each strategy incrementally increased the ability of the future Paulding Hospital to provide a continuum of care throughout the campus lifecycle.

While each strategy adds flexibility to a healthcare project, the ease of implementation, the effectiveness, and potential impact must be studied to determine the practicality for inclusion in a specific project. During the design process, the earlier a strategy is identified and incorporated, the greater impact it can achieve, and the easier it will be to implement.

To view part one of the series, please visit: To see part two, see: