Healthcare facilities were historically designed for longevity, planning for at least 30-50 years of occupancy. Subtle modification like changing a primary care clinic to a specialty clinic or office spaces to clinical spaces was expected, but foundational change such as doing complex procedures in outpatient centers that had traditionally been performed only in inpatient hospitals was not.

With rapidly eclipsing medical technology and equipment, demographic and epidemiological shifts, and fluctuations in policy and regulations, the design field is faced with the unenviable task of addressing what’s necessary today while also anticipating the effect of iterative transformation going forward. In other words, health facilities, especially outpatient clinics, must be change-ready from the very first day they open.

“Clinic 20XX: Designing for an Ever-changing Present,” a 2015 report by the Center for Advanced Design Research and Evaluation (CADRE), found that the core tenets of designing for change were connectivity (between the digital cloud, facility, and community), a sense of place, and flexibility. Notably, researchers also observed little precision in the use and meaning of “flexibility,” which was often interchangeable with terms like “agility” and “adaptability.” Solutions for flexibility cited in the report were wide and varied, from concourse-style waiting rooms to dual-purpose exam rooms to demountable walls and multipurpose furniture.

At the same time, there was confusion about what flexibility really meant and whether it made sense to plan for it up front or to retrofit as needed. Additionally, it seemed that flexibility meant different things to different people. For example, for an owner, flexibility is something that allows a system to offer new service lines and generate more revenue; for a nurse, it’s an adjustment in day-to-day care delivery to allow the best patient care; and for facility managers, flexibility is being able to reconfigure a facility to enable the owner, providers, and visitors to do all they need to do. The challenge for facilities is that the changes could be at different scales (from rapid configuration of furniture, fixtures, and equipment to substantial renovation and new construction) or at different rates (minutes, days, or weeks).

Because flexibility spanned all scales of design and recognizing that the current literature on outpatient care design didn’t have a clear framework that defined the term, the different levels at which it could be deployed, associated time and costs, an actionable approach, or how to reap its benefits, CADRE initiated a cross-disciplinary collaboration between Steelcase Health (Grand Rapids, Mich.) and HKS Architects (Dallas) with the goal to:
• Understand the various definitions of flexibility and nuances of commonly used terminology.
• Understand the needs, challenges, and expectations around flexibility in outpatient settings from three key stakeholder groups: healthcare administrators, nurse managers, and facility managers.
• Synthesize established approaches (within and outside of healthcare) into a simple practice-focused framework for outpatient clinics.
• Validate this framework based on insights from key stakeholders.
After an extensive literature scan, researchers synthesized an approach, called the FleXX framework, based on four core attributes: versatility, modifiability, convertibility, and scalability. These elements were applied across building layers such as surroundings, structure, exterior/building envelop, services/MEP, and space planning. For each of the attributes, the framework outlines agency (whether the user of the space can make the change or facility intervention is needed), ease (how quickly and over what time the change can take place), cost (conceptually compared across the different attributes at different stages of design and delivery), and reversibility (something possible with versatile and modifiable solutions but more difficult when involving renovations or new construction).
  Versatility—Allows the user to engage in different activities without making any built environment changes, such as fluid multipurpose zones replacing waiting rooms where people work, interact, self-educate, and (sometimes) shop as they wait for their appointments. Open hall spaces, multiuse spaces, flex lab spaces, shared spaces, and specialty groupings are common examples of versatility.
  Modifiability—Gives the user agency to quickly change a space or object without relying on support from the facility or contractors. Multifunctional furnishings for family in the patient room, adjustable workstations, mobile carts, rolling partitions, or patient-controlled shades are all examples of this concept. Stakeholders mentioned movable partitions, modular/mobile furniture, and standardization as key investments.
  Convertibility—Transferring agency from the user to facilities and design teams, convertibility is the ability to replace the infill of a building to serve a new purpose. Like shipping containers that can be converted to a tiny home or an emergency shelter, outpatient clinics can convert existing rooms into administrative or exam functions. Other examples include multiple exam rooms that are conjoined to create a procedure room and shell spaces that are ready for conversion to whatever future need. Convertibility isn’t possible unless infrastructure affordances like medical gas availability, ceiling heights, and structural strength have been planned early. Converted spaces can rarely return to their original state without further investment.
  Scalability—Also transferring action to facilities and design teams, scalability is characterized by the ability to grow or shrink through minor or major renovations. While we have seen many examples of facility expansion, a physical shrinking of the footprint remains an elusive goal. An International Space Station-like clinic where units get added and removed, as needed, would be a truly scalable solution. Mobile clinics might also hold great potential if they gain traction in the industry. Within many multispecialty clinics, we see operational scalability (growing and shrinking of service lines) by space convertibility or modifiability.

Stakeholder perspective
To evaluate the validity and usefulness of the framework, the team deployed a nationwide survey in early 2018. The survey asked 40 healthcare administrators, 51 nurse managers, and 37 facility managers about flexibility in outpatient environments to determine meaning, drivers, desired qualities, business case arguments, and strategies for implementation.

Eighty-one percent of stakeholder respondents said they regard flexibility and adaptability as interchangeable terms. However, when asked to define flexibility, the most common response was that the built environment was something that must be flexible in order to adapt. That is, there’s a distinction between the affordance of a building (flexibility) and its purpose (adaptation to market, operational, climate, or other drivers).

Because of the high investment required to achieve convertibility and scalability, it’s not surprising that stakeholders rated versatility (4.5 on a scale of 1-5) and modifiability (4.4) as more important than convertibility (3.9) and scalability (4.0) for outpatient design. But this finding is also consistent with their top three considerations for flexibility: more space, multipurpose space, and a modifiable sensory environment. These are simple attributes that can be achieved by creating spaces with significant user control, such as privacy, lighting, and temperature, or by allowing spaces to be used for more than one purpose using changeable room signs and generic room names.

More than 70 percent of stakeholders stated that flexibility doesn’t necessarily increase cost (it’s a part of good design), especially when cost is assessed over the lifecycle of the building. However, scalability was the only level of flexibility for which they are willing to pay a premium (up to 20 percent). Interestingly, a scalable solution, such as reducing the footprint of a clinic, may rely on convertibility (converting existing clinic space to retail areas or community areas).

Within their facilities, stakeholders reported that modular workstation (2.9 on a scale of 1-5) and casework solutions (2.9) were more common than demountable walls (2.3), prefabricated exterior panels (2.1), and prefabricated rooms (2.0). They also indicated that reconfiguring the patient room with modifiability and versatility is a common, successful flexibility practice. And while 88 percent of stakeholders mentioned the use of standards, only 48 percent thought that standards improved flexibility. Notably, however, the research team found that modular solutions are more likely to be used in practices with standards. This set of findings suggests that the approach to standards and modularity is not fully integrated or realized.

Importantly, qualitative data suggested that an owner may be thinking of “operational” scalability but building “convertibility.” For example, a recent project includes an outpatient clinic designed to adapt to a freestanding inpatient hospital in the future. In addition to the capability to scale vertically and horizontally to add services, two levels of the current clinic are planned to be converted to inpatient operations. An early conversation about how a system wants to grow can reduce the risk of over-designing and underutilizing flexibility affordances by layering operational aspects of flexibility on spatial solutions.

Stakeholders in our sample also held varied opinions about the return on investment (ROI) for flexibility. While desiring some combination of organizational growth, improvement in bottom line, ease of change, increase in patient satisfaction, and improvement in employee satisfaction over the first five years, a clear metric by which ROI for flexibility can be assessed is missing. Part of the challenge is that financial information comparing facilities that were designed with flexibility early on with facilities that retrofitted/renovated based on needs as they emerged has not been done.

Next steps
The FleXX framework clarifies flexibility by attribute, including who changes or makes the change, the type of change, the ease of change, and the cost of change. It’s anticipated that using a common platform like this for conversations between owners, designers, and planners will enable transparency and understanding during planning as well as mobilizing flexibility in outpatient settings. The next step for this study is to test the FleXX framework in real projects and study how flexibility can be planned, designed, and strategically mobilized to provide a meaningful impact and sustainable ROI.

Upali Nanda, PhD, Assoc. AIA, is the director of research at HKS, executive director of CADRE, and associate professor of practice at Taubman School of Architecture and Urban Planning. She can be reached at Michelle Ossmann, PhD, MSN, Assoc. AIA, is the director of health environments at Steelcase Health and research scholar at the College of Design, Georgia Institute of Technology. She can be reached at