This three-part series will explore the topic of flexibility in architecture. In this first article, we examine the main reason for flexibility: change.

By studying the ways our buildings have evolved, we can begin to understand the demands we will place upon them in the future and the necessity for flexibility.

The second article will present three types of flexibility (convertibility, adaptability, and transformability) and how they can be beneficial to the healthcare field. The third article will study how flexibility is incorporated into the design process, along with specific architectural responses to different flexibility strategies, presented through case studies.

To read part two of the series, please go here: To read part three of the series, please go here:
A changing field
Like technology, the medical field experiences rapid progress. Significant advances change how patient care is administered and supported, and oftentimes require new technology, equipment, or spaces. With changes in care delivery technology occurring so rapidly, and in light of economic constraints and environmental concerns, it is not feasible for healthcare institutions to construct new facilities each time technology changes.

Many drivers exist in the design industry to create innovative, unique, and successful projects, but none is more paramount than flexibility in realizing the full potential of a facility. The ability to accommodate changing standards of care and space requirements reduces service disruptions, medical complications, and the need for capital expenditures to construct new facilities.

As a result, an increasing number of healthcare facilities are emphasizing flexibility when planning their buildings.

The challenge is twofold: Institutions must prepare and plan for a future they can’t predict; and, historically, efforts toward flexible architecture have focused on building typologies outside of the healthcare sector that tend to be less regulated.

Healthcare designers and planners are uniquely positioned to implement flexibility strategies; this can extend the life cycle of a structure, reduce future renovation cost, and reduce the impact of construction projects on the organization’s processes and culture.
Types of change
In order to understand how flexibility can benefit healthcare facilities, it is important for designers to understand the types of change that hospitals might experience.

Although some fluctuation in patient volumes is normal, a sustained change in volume can occur in areas that are growing or decreasing in population, such as a revitalized urban core or a rural town that has just lost a major employer. Greater volume can tax every aspect of a hospital’s facilities, from publicly accessible restrooms to operating rooms and patient rooms.

On the other hand, a decrease in volume means that the facility must provide maintenance for underutilized spaces.

A hospital can also experience a volume surge after a natural disaster. In the last 10 years, various communities have experienced an increased need for care following hurricanes, tornadoes, earthquakes, and tsunamis that have crippled healthcare systems.

In these circumstances, healthcare systems grapple with diminished or damaged physical environments and limited supplies, in addition to increased volume and acuity of patients.

Service lines
Market changes or a shifting demographic can prompt a change in a hospital’s service lines. An aging population would produce a higher volume for the cardiac, oncology, and geriatrics departments, while a growing young population would produce higher volumes for the obstetrics and pediatrics departments. The decision to launch, close, expand, or consolidate service lines has repercussions on the physical environment.

Patient mix and standard of care
Changing standards of care affect how facilities are utilized; surgeries that once required admission to the hospital are being performed on an outpatient basis. This trend shifts patient mix volumes and can find some hospital facilities overloaded and render others underutilized: Inpatient units become less utilized, and prep and recovery rooms experience higher demand.

Although modern advances have resulted in smaller and better equipment, the size of clinical spaces has been steadily increasing to accommodate more individual pieces of equipment. In addition, the shift toward private patient rooms has increased the total square footage within a facility dedicated to patient rooms.

In the 1980s, hospitals averaged about 1,100 square feet per bed. Twenty years later, that average is around 2,300 square feet per bed. (James Hosking, Replace or Renovate? Journal of Healthcare Management, 2004)

Medical discovery 
The emergence and discovery of diseases coupled with medical advances and new treatments also affect the landscape of healthcare environments. The technology that revolutionized cancer treatment also brought about a need for a new type of space: infusion suites.

Conversely, the sun decks so prevalent in Alvar Aalto’s Paimio Sanatorium became obsolete as soon as antibiotics became the standard treatment for tuberculosis.
Dimensions of scale in time and space
Each type of change operates at different dimensions of scales in time and space.

Some types of change occur within the span of one day; other changes take longer, such as a departmental renovation or the conversion from semi-private rooms to private patient rooms. On a larger time scale would be new construction projects, which oftentimes take years to come to fruition.

The second dimension, space, refers to how much is involved in the change (size, essentially). Change affecting one patient room is not the same as that which affects a whole campus. When referring to space, we can see change happening in rooms, departments, floors, buildings, campuses, and—for health systems with multiple locations—in cities, counties, or states.
Why flexibility?
Delivery of care is under constant scrutiny for efficiency and effectiveness. Hospital administrators are increasingly aware of market share and revenue streams; policy makers are held accountable for processes and conditions that may result in medical errors, nosocomial infections, and patient injuries.

A facility that provides care efficiently and effectively reduces the overall cost burden of the system. Although many changes can be accommodated with short-term engineering, operation, and process modifications, a more permanent solution often is needed. Improvements in the care delivery process can be supported, even encouraged, by the built environment.
The layers of change
A tool for understanding change, the concept of shearing layers was developed by Frank Duffy and expanded by Stewart Brand in his book “How Buildings Learn.” The theory breaks down our environment into 10 layers: site, strategy, shell, structure, skin, services, space plan, scenery, sets, and stuff.

The model is usef
ul in understanding that change happens at different rates; within a building’s life, the “stuff” such as the pencils on our desks, our computers, and chairs will change more quickly and more often than the “site” or “structure.”

The different layers also reflect the amount of effort required, and how easily the change is achieved. It is much more complicated to alter a building’s structural grid than to shuffle around desks.

When evaluating current or possible change situations, it is important to consider the shearing layers concept when drafting a strategy. A plan of action must address each level in response to the type of change experienced; this will facilitate an optimal solution with the resources available.

Robert J. Farrow, AIA, FHFI, LEED AP, is Principal and Senior Vice President at HKS Inc.; Amaya C. Labrador, Assoc. AIA, CDT, EDAC, is an Intern Architect at HKS Inc.; and Joshua D. Crews, Assoc. AIA, EDAC, is an Intern Architect at CDH Partners Inc. For more information, please visit