The Future of Flexibility in Healthcare Design

In a recent post on this very blog, Elizabeth Cox and Alison Laas introduced what a series considering how generational and cultural differences will drive change in healthcare design. Alison followed that post by provocatively questioning the future the typical exam room, and Elizabeth added depth to the discussion by looking specifically at differences between the Baby Boomers and Millennials. While not specifically the focus of any of these posts, directly relevant to each of them is the question of how institutions should approach the act of building given the certainty of profound cultural and technological changes. As revealed on the Fast Company: Design blog, that very question was at the heart of the design process for the Alexandria Area High School in Alexandria, MN. Architect John Pfluger neatly summarizes the issue in observing that “[d]esigning an environment that can take kids into an unknown future is a real challenge. … We know things are going to be more different in the future that we can possibly expect, so how do we address that uncertainty?”

While there is no denying the importance of the questions raised in these posts, in the broadest sense of things there is nothing unique about a time in which foreseeable but unknowable changes are poised to exert a profound influence on the world we live in. To the contrary, I can say with certainty that change is one of life’s very few universal constants. I can also say with confidence that from the time of the primitive hut imagined by Laugier, buildings have either accommodated change in some acceptable way or they have been torn down. Given the constancy and universality of change, it is perhaps surprising then to suggest that as a profession we are not doing nearly enough when it comes to understanding and measuring the economic impacts of change. More surprising still is the absence of any commonly understood and accepted methodology for determining the ideal set of investments a building owner should make in providing flexibility to accommodate the changes that will inevitably come.

To digress from the question of flexibility for just a moment, in the relatively recent past our industry has seen an extraordinary rise in the emphasis placed on sustainability in general and building performance specifically. This rise has been accompanied by an expectation that design teams do more than merely rely on their best judgment to determine how to design a high-performance building. It’s not necessarily the case that our judgment was wrong, it’s that our judgment is insufficiently precise to make small but measurably important distinctions between options. In its place we have seen the rise of rigorous analysis that can quantify, and therefore justify the fundamental design decisions we make that relate to building performance. This critically important replacement of judgment with quantitative analysis is properly understood as a bellwether moment for our industry as it marks a transition to a world in which critical design decisions are being measured relative to how much value they create for building owners. While it is certainly true that there are different ways to measure that value, the significance of the fact that it is being measured should not be underestimated. The introduction of rigorous, quantitative analysis into the design process has empowered design teams and owners to make informed choices about how to maximize the value they create with the capital they invest in a building.

Given the already discussed inevitability of change, it is perhaps surprising that it is rarely (if ever) the case that decisions regarding provisions for future flexibility are subjected to the same sort of scrutiny and critical analysis that building performance related issues receive. Even in cases where institutions require specific accommodations for future flexibility, it is most often the case that the applicable metrics are rooted in estimations and perceptions of institutional experience as opposed to a value-based quantitative analysis. There may be many reasons why this is the case, but surely one of them is that measuring the value created by a particular investment in flexibility is significantly more complicated than measuring the value of a building performance related issue. When considering building performance issues, project teams are frequently dealing with a binary set of either/or choices. In their most complex form, teams might consider connected sets of several possibilities yielding multiple possible outcomes, but the decisions to be made are generally fixed choices between known options. In order to properly value an investment in flexibility however, teams must consider a wide range of possible future states, the probabilities of occurrence, the opportunity cost of the investment, and the timeframes within which a particular investment can be exercised. As such, this form of valuation is substantially more complicated than a single future forecast discounted cash flow analysis, but it can more clearly identify investments that optimally mitigate risks and/or capitalize on future opportunities. Notwithstanding the complexity of the analysis, given the significant investments that many institutions currently make in future flexibility the development of appropriate analytical tools that can reliably measure the value created by different flexibility options represents a new frontier along which design teams can aid building owners in their efforts to create as much value for their capital project dollars as possible.

The time has come when design teams should both seize the opportunity and shoulder the responsibility to provide better information to our clients regarding flexibility related design decisions. PAYETTE, working with colleagues at Affiliated Engineers, DPR Construction and The Capital Projects Group is leading the charge to develop a rigorous approach for measuring the value of flexibility and communicating that value to our clients so that we can try to move beyond ‘rules of thumb’ and start to bring meaningful analysis to bear on the decision making process. Over the course of the next several months we will periodically report the insights we’ve gained and the progress we’ve made along these lines. Stay tuned for those updates – they just might change the way you think about the future!

Related:
Cultural Shifts Transforming Healthcare Design: An Introduction
Does Remote Health Monitoring Mean the End of the Exam Room?
Adapting Healthcare Design to Accommodate Future Generations