Healthcare Design - August 2019 - 52

FOCUS

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 crossdisciplinary 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.

AUGUST 2019

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S TA K E H O L D E R P E R S P E C T I V E

SPOTLIGHT ON

HCD EXPO
To learn more
about designing
for flexibility, check
out session "E79:
FleXX: A Framework
for Flexibility, Tested
in Practice" at the
2019 HCD Expo &
Conference, Nov. 2-5
in New Orleans. For
conference details,
visit HCDexpo.com.

HCDMAGAZINE.COM

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

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Healthcare Design - August 2019

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