Hospitals in Flux

The Dynamic Nature of Modern Healthcare Environments

Modern hospitals are undergoing major renovations unseen since the last great construction boom following WWII.
The actual dynamics of these changes have remained hidden in the face of the over $15 billion a year scope of these
changes. MKThink undertook an extensive research project using both primary and secondary data analysis to understand
the nature of these dynamics. The goal was to provide the larger health care industry with insight into the nature of these
changes. Our research and analysis revealed interesting patterns and led to design recommendations based on these
findings.

An MKThink Research Publication

28 July 2005

For further information, please contact:

Chloe Lauer at 415 288 3394
Hospitals in Flux
The Dynamic Nature of Modern Healthcare Environments
F or many, the modern hospital stands as symbol of technological
mastery, order, and control in the face of the chaos that illness
brings to the social fabric. When one lifts the hood on the
modern hospital, however, one is struck by just how much flux
and change is taking place within the halls of these central social
institutions.
Hospitals are experiencing a wave of construction and
renovation unseen since the construction boom following WWII.
Hospital construction activity was measured to be around $15
billion in 2003,1 driven largely by decaying and obsolete
facilities, changing patient demographics, seismic codes, and
technological advances.
With approximately 4,800 registered U.S. hospitals,2 this
translates to approximately $3 million per hospital in construction
and renovation each fiscal year. To put this into perspective, with
revenue per hospital averaging $70 million per year,3 renovation
costs equal almost 4% of yearly hospital revenue.
Another way to understand the impact is to look at hospital bed
availability. Each year the total hospital square footage offline
due to construction is equivalent to 215 entire hospitals. The
scope and scale of these changes is extensive and continues to
grow each year.
Faced with such extensive change, hospital design is moving
away from traditional “brick and mortar” construction paradigms.
The move towards long-term facilities planning, modularity, and
design around a technology-enhanced workflow are all part of a
series of design trends reshaping the architecture of hospitals and
the larger healthcare built environment.
Hospitals in Flux © MKThink 2005. Reproduction prohibited without permission.
THREE PRIMARY DRIVERS FOR CHANGE
New technologies, increasing focus on patient/family-centered
spaces, and the competitive pressure for services all are forcing
hospitals to adjust their physical environments accordingly.
New technologies. Wireless patient record keeping and
increasingly sophisticated imaging technologies are driving the
need for space allocation dedicated to tech support and IT
systems.As new technologies enter the hospital, work flows are
influenced. This, in turn, affects planning and space allocations.
Patient/Family Centered Space. Patients and families are
increasingly demanding a variety of amenities to make their
hospital experience more “home-like,” such as single family rooms
and comfortable, hotel-like waiting areas.
Competitive Pressures. Both the pressure to keep up with the
competition and the desire to improve efficiencies are forcing
hospitals to realign their facilities in the face of increasing fiscal
pressures, demographics, and patient needs.
These changes in hospital facilities are only expected to increase
over time. The need for hospitals to adapt to these various drivers
is accelerating. This need creates increasingly dynamic conditions
in the hospital built environment.
SCOPE AND SCALE
The changes taking place in hospital facilities are ubiquitous
and extensive. Over 2/3 of U.S. hospitals are in some state of
transition. Of these, most of the hospitals under renovation are
larger—over 240,000 s.f. with 250 or more beds.
Project costs vary widely for a given fiscal year, ranging from
$110,000 to $100,000,000. Most hospitals are regularly
allocating funds to facilities upgrades and improvements as new
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technologies, shifting Full Time Equivalents (FTEs), or changing
patient needs put pressure on the extant facilities.
In California in particular, State Bill SB 1533, focused on seismic
retrofitting, has led to major expansions of hospital renovation
and construction. Besides upgrading for seismic retrofitting,
many states are mandating changes in hospitals due to outdated
materials and higher standards for healthcare excellence.
TECHNOLOGY DRIVES REGULAR CHANGE
Technology is one of the primary drivers of facility change. In
particular, the increasingly prominent role of complex imaging
and diagnostic modeling technologies is demanding an increase
in infrastructure support. As these technologies become more
sophisticated, new rooms, data cabling, and conduits must be
created in accord with changes to hospital space planning tied
to new workflow patterns. In addition, workflow patterns based
on the traditional “tower and pancake” model of hospital design
with multiple floors dedicated to different specialties often does
not mesh with the increasingly interconnected and interdisciplinary
nature of technology driven healthcare.
Because of these shifts in technology, and the obsolescence of
facilities, hospitals are making changes due to technology on a
regular basis (Figure 1).
FIGURE 1: Frequency Of Technology Driven Changes,
2000-2005 (Per Facility)
100%
construction work required.”5 The bottom line for many facilities
managers is that “patients always need the newest, latest, greatest
care. Technology has to keep up with every aspect of patient
care.”6
The number of these renovations over time illustrates the dynamic
nature of the hospital environment driven by technological
change. Consistent renovations and regular expenditures due to
obsolescence in technology and other factors drive these changes
in a way that make the interior environments of modern day
hospitals one of significant fluidity.
PATIENT/FAMILY CENTERED SPACE
As the hospital amenities competition heats up with increasing
demand from patients and families for comfort and control,
hospitals are forced to adjust their rooms to accommodate family
needs more directly. The overall thrust for many facilities managers
in this regard is “making the buildings more patient friendly.
[We are] looking for ways to facilitate expansion of community
services.”7
One of the major changes in alignment with this trend is the
creation of single rooms (Figure 2). The demand for single rooms
with accoutrements found in hotel suites is a growing concern for
many facilities managers, who feel that they have to “improve the
patient and family experience”8 by creating facilities that match
the needs of the users.
FIGURE 2: Patient/Family Demand On Hospitals
100%

80%
80%

60%
Percentage

Percentage

60%

40%
40%

20%
20%

0%
0 2 5 10 10+
0%
Frequency
s s s s s es
om om ea om om ac
Ro Ro Ar o Ro Sp
Roughly 70% of respondents reported having had to make
4
le ily g rR h
ng tin ve Te
c in
g
changes over five times per year in their facilities due to outdated Si Fa
m ai yo al
W a He
St
facilities not meeting the needs of new technologies. New and
improved wireless services, IT services, diagnostics and imaging, COMPETITIVE PRESSURES - CHANGING SERVICES
electronic medical records, MRI facilities, and catheter labs all
require major renovation of space to accommodate new work Patient and family demand for particular services, changing
flows, or provide room functionality not available in original service offerings, and the creations of focus factories (centers
configurations. of excellence) are key factors driving the needs of facilities
A Facilities Manager at a major California Hospital in the Bay renovation.
Area commented, “We continually upgrade our CTs and MRIs
to the latest technology. There is always some renovation/

Hospitals in Flux © MKThink 2005. Reproduction prohibited without permission. Page 3

Patient demand for specialty services ranging from cardiac cath
labs to fertility clinics are increasingly driving hospitals to make
changes in facilities to keep up with competitive demands. Like
any other industry in a consumer driven marketplace, hospitals are
under increasing pressure, as informed patients demand better
accommodations and excellence in treatment. This is forcing many
hospitals to become more responsive to remain competitive in an
increasingly consumer driven marketplace.
In addition to expanding service offerings, hospitals are also
faced with pressures to improve operating efficiencies. The
imperatives of HMOs and other business performance criteria
are forcing hospitals to consider both the expansion of profitable
and consumer marketable services, but also the cutting and
scaling back of all forms of redundant and inefficient facilities and
procedures. To quote one facility manager, “The goal is to figure
out how to do more with less, and do it better.”9
FLEXIBILITY AND CHANGE AS NORM
Future trends point to increased changes, with over 68% of
respondents10 believing that the extent of renovation will increase
over the next five years (Figure 3). With increased volume and
a desire to improve patient satisfaction, coupled with changing
technologies and the desire to meet patient demands, the future
of hospitals will continue to require change. Technology, patient
demands, and the fluctuation of particular service offerings will
all drive a more dynamic and fluid internal environment that must
continually adapt to change and novelty in the healthcare world
of the future.
FIGURE 3: Renovation Anticipated, 2005-2010
100%
80%
60%
Percentage
40%
20%
0%
More Less The Same
Extent of Renovation
CURRENT AND FUTURE DESIGN TRENDS
Because of the increasingly fluid technology and consumer driven
dynamics of the health care environment discussed above, there is
an opportunity to move away from traditional “brick and mortar”
hospital construction towards more flexible environments where
change can be accommodated and addressed rapidly and
Hospitals in Flux © MKThink 2005. Reproduction prohibited without permission.
efficiently. Several implications for planning and design arise from
these trends:
• The creation of core centers of excellence. These “Focus
Factories” for specialty services like cardiac or orthopedics,
which draw attention to hospitals just as university departments
are known for their particular areas of specialization. This
allows a hospital to create attractive and marketable service
packages that are recognized and sought by increasingly
sophisticated healthcare consumers.
• Hospital planning will be increasingly focused on
adaptation. Hospitals will shift from short term, reactive
response to change to incorporating change into long term
planning and design. Hospitals will use more thorough front
end strategic and scenario planning as a key feature in hospital
design to plan and adapt to changes over time.
• Design around workflow and current care models. Hospitals
increasingly will follow design models like airports where a
core hub with all centralized services provides a terminal area
from which people will be directed towards specialized needs.
Instead of traditional “towers” with departments, hospitals
will follow an information model with hubs, nodes, and
communicative corridors as the core design elements.
• Pervasive and distributed computing. Hospitals of the future
will be highly wired with digital patient record keeping,
wireless diagnostic devices, and other forms of information and
collaboration enhancing tools to enhance productivity, and
track and adjust to shifting conditions rapidly. Like El Camino
Hospital in California, one of the nation’s most wired health
care environments, workflow and hospital facilities will need
to be adjusted to the role digital technology plays in “ABC”
(Activity Based Computing) as more diagnostic, treatment, and
recovery is supported by digital devices and work processes.
• Hospitals will increasingly be modular. Generalized rooms
will be fitted with core elements that can be easily swapped
out to address patient or staff requirements as demographic
trends and patient needs shift over time. Instead of building
a fixed design, fluid environments will be created which can
adapt to change as needed.
• Integrative medicine integrated in workflow and space
planning. As demand for integrative medicine grows in
modern healthcare, the integration of wellness centers into
the overall hospital environment and work plan will need to
be accommodated. The creation of a global integrative care
model will affect how spaces are planned, shifting from rigid
departmental floors to a more holistic approach to total care.
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CONCLUSION

The modern hospital built environment is one of constant change,

forced to respond to external drivers putting significant pressure
on outmoded facilities. Adapting these changes requires continual
renovations by facilities managers who must make choices to
address a variety of new pressures.

In order to respond to the increasing pace of technological

change and competitive pressure, hospitals will have to embrace
new design and construction paradigms that support flexibility
and adaptability.

A focus on thoughtful planning and research is a core element

to success in this process. The more forethought, research, and
analysis, both qualitative and quantitative, that goes into the
planning process, the higher the likelihood of success.

Hospitals in Flux © MKThink 2005. Reproduction prohibited without permission. Page 5

NOTES
1. Reed, Abelson. “Hospitals, Eager to Build, May Find Funds
Scarcer,” New York Times, 15 June 2004.
2. American Hospital Association, available from
http://www.aha.org/aha/about/index.html.
3. U.S. Census Bureau Report. “Hospitals: 2002,” 2002
Economic Census: Health Care and Social
Assistance Industry Series, August 2004; available from
http://www.census.gov/prod/ec02/ec0262i02.pdf.
4-10. MKThink research, January 2005
Hospitals in Flux © MKThink 2005. Reproduction prohibited without permission.
COMPANY PROFILE
MKThink reveals and opti mizes the nexus between people and
their environments. Led by principals Mark Miller, Steve Kelley and
Nate Goore, MKThink creates dynamic strategies that help solve
organizational challenges.
The MKThink team, comprised of anthropologists, psychologists
and business people, as well as architects and urban planners,
strives to fully understand their clients’ identities, needs, goals
and culture before ever putting pen to paper. With a strong
background in learning, workplace, community and healing
environments, MKThink boasts a wealth of capabilities, including
strategic, analytic and design services.
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