Healthcare projects, more than most, must accommodate major change. A new formal approach to this is emerging

by STEPHEN KENDALL, PHD, RA

The fact that hospitals undergo physical change has become a subject of interest on an international level. These changes are of great concern to healthcare organizations—and to governments—because of the rising costs of construction and the need to control those costs as buildings adapt and expand over time. This interest is not new—understanding how facilities change through varying cycles came to our attention in the 1960s with renewed vigor when “systems” buildings became the subject of research. The U.S. Veterans Administration building system is a good case in point, with its innovative interstitial floor concept developed in the 1970s and used in a number of projects since.

That was also when a “life cycle” understanding of buildings emerged as a subject among building economists. Despite knowledge developed about the importance of the “long view” in life-cycle analysis, however, economic incentives still favor the short term. This is exacerbated by the fact that health care systems usually operate with one budget for new construction and another for maintenance and operations. Two “turfs” competing for resources do not necessarily support the kind of investment decisions needed to prepare buildings for the long haul.

While hospitals “churn” incessantly, little systematic research is being done on how hospitals change. This doesn't mean that architects, contractors, product manufacturers, and clients have been able to avoid this challenge—many have worked hard to solve these problems ad hoc. Architects, consultants, and their clients couldn't survive otherwise, and no doubt much has been learned in the way of principles and methods. However, few in practice have time to reflect upon and capture lessons acquired from daily work in any organized way. As it turns out, the more we focus on it, the more we find that our theory on the subject is weak.

In short, we don't have a good way of explaining how hospitals are designed and how they change over time. What is generally heard is we should “design column-free spaces,” “make floor-to-floor height greater,” or, “don't bury pipes in concrete.” These guidelines are important, but they don't constitute theory.

This “theory deficit” is important and serious. When I say “theory,” I don't mean what we want to happen (as in a manifesto), but what we understand about how things work. In that sense, good the

most practical thing we can have. Without it, our work is less well grounded than it should be.

Parallels to Other Building Types

There is evidence that hospital system clients, in the knowledge that their buildings are never truly finished, are asking architects and engineers new questions, with varying results. Some are building “shell” space because they have no way to predict what will later be filled in. Perhaps more importantly, smart clients are asking for demonstrations, beyond rhetoric and pat answers, of how their buildings will accommodate change when technical and organizational decisions are constantly in flux.

This is how office buildings, shopping centers, laboratories and, increasingly, housing developments around the world that follow “open building” principles address decision flexibility and long-term capacity for change in very matter-of-fact ways. Now, some healthcare projects are being designed similarly. The Banner Estrella Medical Center project in Phoenix designed by NBBJ and Orcutt/Winslow Partnership is one healthcare example pointing in the right direction, as is the Gonda Building at the Mayo Clinic in Rochester, Minnesota, designed by Ellerbe Becket. Both have established a loose-fit connection between the base building (defined in terms of accommodation capacity) and the structural, spatial, and equipment needs of the fit-out. There are a number of other exciting projects under way in Europe, including a new hospital in Belgium designed by the Austrian firm Baumschlager and Eberle, and the Erasmus MC University Hospital in Rotterdam designed by EGM Architects in the Netherlands. These projects also formally establish this loose-fit relationship between the base architecture and its changing fit-out.

The INO Hospital Project

One of the most clear-cut, methodologically rigorous approaches to designing change-ready hospitals is being used in a pioneering project in Bern, Switzerland: the INO project at the Insel University Hospital, managed by the Canton Bern Office of Properties and Buildings (OPB). An international peer review of this project took place in July 2006 in Bern, with sixteen architects, hospital facilities directors, and researchers from the United States, United Kingdom, and the Netherlands taking part with their Swiss counterparts. (Please contact the author to learn more about this.)

Although the problems faced by the OPB are highly technical, the first order of business at the INO was not to invent new technical systems (like the Veterans Administration Hospitals' interstitial floors), but to rethink the paradigm of facility procurement and design management. This innovation is primarily organizational, but the consequences are architecturally and strategically compelling.

The INO project is a 50,000-square-meter addition to a large university hospital campus in Bern. It's one of the biggest hospital projects ever built in Switzerland. When the decision was made to go to the Canton Bern government for funding, the argument was that complex buildings such as this only become “whole” over time. The Canton Bern OPB had come to realize, after many conventionally procured buildings, that inevitably their buildings' functions change to meet new medical procedures, new regulations, and new market and insurance conditions.

Recognizing these dynamics resulted in the management team, led by chief architect Giorgio Macchi, adopting an entirely new process for procuring the facility. A competition (a normal process of architect selection in many European countries) was held to select a design and construction firm for each of three distinct “system levels.” Ten firms were invited to submit proposals for the primary system.

The primary system's base building is intended to last 100 years and is expected to accommodate changing departmental sizes and changing layouts of emergency, imaging, surgery, and pharmacy departments, zoned for specific floors (the building was not designed to have nursing units). The secondary system—which indeed has already accommodated changing sizes and&