Outbreaks of infectious disease are becoming more frequent, as the world becomes more connected and rising global temperatures create more favourable conditions for the transmission of disease. In the previous part of this series, we considered what resilient healthcare looks like in a post-pandemic age, and how we can apply the lessons of COVID-19 to better prepare for other threats to resiliency, such as climate change. In this highly networked world, we have found that a system-wide view is essential for resilience planning. In this article, we’re taking a closer look at what resilience actually looks like for individual healthcare facilities. It comes down to one concept above all: viable flexibility. 

Even before COVID, there was a growing recognition that buildings of every kind needed to be more flexible, as technological change far outpaces the development cycle. But in practice, any redundancy in a design has often ended up on the cutting room floor, because it adds cost, or complexity, or because it is not compliant with building codes or standards. The pandemic has added powerfully to the case for flexibility – disrupting operations in every part of the built environment, and promising to disrupt markets for many years to come.

In healthcare, a gargantuan effort was required to replan and reengineer buildings almost overnight so that they could safely cope with COVID-19, and attention is turning to how the switch to “pandemic mode” might be made more easily in future. Greater flexibility would have helped this time. It will make us more resilient in future outbreaks. But it can also help us to overcome existing gaps in provision, to respond to other radical changes that we know are on the horizon, and to changes that we can’t foresee.

“All we know is that there will be change,” says Suzanne MacCormick, global healthcare lead at WSP. “One of the many lessons of this crisis is that flexibility of space is paramount to enable optimum resilience and provide readiness for the unknown. Instead of ‘value engineering’ out everything that makes a project resilient, we should engineer in added value.”

In many places, the immediate response to this crisis was to provide surge capacity by converting large buildings such as stadiums or conference centres, or by constructing entirely new field hospitals from scratch. For the future, this strategy is shifting to provide extra capacity within hospitals themselves, or in very close proximity, so that they can more easily access the staff, equipment and infrastructure they need.

This time, the switch to “pandemic mode” has involved reconfiguring hospital entrances and layouts to separate infected and non-infected patients and associated flows of staff, equipment and consumables. Intensive care units (ICUs) were scaled up to care for a surge in critically ill patients, and isolation rooms improvised by installing fans and filters to create negative pressure. For the next time, greater flexibility in both spaces and systems can make the transition smoother and more effective. ICU rooms, for example, need a higher level of emergency power redundancy and a medical gas supply for patients on ventilators, and the hospital infrastructure has to be able to supply a much higher demand for oxygen. 

“Converting normal patient rooms to ICU rooms is not plug-and-play,” says Gary Hamilton, healthcare practice leader at WSP, based in Washington DC. “You can’t just plug in all the equipment that’s required to keep the patient alive because the requirements are very different.” On one conversion project, he found that the medical gas system could be stretched a little – but that the hospital pipework wasn’t big enough to carry the higher loads. “We could have increased that during the design with a marginal effect on the whole infrastructure cost, and we wouldn’t have had a problem. But we weren’t designing for a pandemic. This is unprecedented, but it’s teaching us that instead of designing to the minimum the code allows, it’s important to take a flexible approach.” Other relatively minor design changes include installing an extra set of entry doors and extra fire doors between departments, to aid separation and compartmentalisation. 

But exactly how far should we go? How much should owners and design teams try to anticipate the future, and what level of flexibility is it worth paying for today? Engineers already consider the interplay of emergencies from natural disasters to mass shootings, and the pandemic adds another layer on top. Raising code minimum could make the process easier, says April Woods, a vice president with WSP in Florida. She thinks the impact of COVID will be comparable to that of Hurricane Andrew, which devastated the state in 1992. “That changed a lot of the building codes here and up the coast, for all buildings and also very specifically the resilience of healthcare facilities. In the coming years, I think greater flexibility will just become a standard of care that we have to implement in all of our designs – for example, to allow the engineering systems to be quickly changed to accommodate a pandemic. When those become code-required elements, owners don’t have to decide whether to opt into something or not.” 

We don’t only need flexibility to be able to go into pandemic mode, we need to be able to move beyond it too. “A lot of the things we are upgrading now are very specific to the virus that we’ve been fighting, and they’re not necessarily a reflection of all the improvements that are needed,” says Sarah Wallwork, principal consultant in WSP’s UK healthcare advisory team. “We need to design space that can be used for alternative purposes when it’s not required for a pandemic. When additional intensive care unit beds are no longer required, you could potentially use that area as a high-dependency unit or a paediatric ICU or as an overflow ward in winter, even for training. As long as you have a building that is built to the required standard and specification, it could be used for a number of things.”

 Around the world, work is already underway to review building regulations and standards, not only on hospital buildings but the guidelines that govern their operations too. This is an essential part of not only formulating solutions but making them affordable, says Steve Eiss, executive director of facilities development at Banner Health in Arizona. “If you want to create flexibility in design, you also have to create flexibility in use, or the cost curve is going to get bigger and bigger. The rules are very structured on what type of patients are allowed to be in what type of room, so you could spend more money to make certain areas flexible, but lower the types of patients that are allowed to be there, and your utilisation ratio is going to get smaller.”

Under the current circumstances, any extra spending at all might seem like a very big ask. But COVID is forcing governments and healthcare providers to make major investments today, and we can’t afford to waste this opportunity. “In South Africa, there is a long list of facilities that are inadequate or that needed additional capacity even before COVID-19, but there was no funding available,” says Jabulile Nhlapo, an associate at WSP in Johannesburg. “The pandemic has brought these challenges to the forefront and it’s forcing the public sector to address these running issues. Attaching a field hospital can provide capacity that’s been needed all along, so when designing we’re thinking about the future use, both in the building materials and the building systems.”

Nhlapo has noticed that clients are a lot more receptive to new ideas, such as prefabrication using lightweight steel and modular buildings that can be adapted or relocated after the pandemic. “Right now the facility would be used for a COVID ward, but in future the walls can easily be rearranged in order to create a long-term layout or to provide a general ward.” Some structures may be dismantled and individual modules recommissioned as clinics in remote communities. She says that they have been proposing these building methods for some time, “but there is a stigma – if it’s not brick and mortar, it’s seen as substandard. Now there is a lot more acceptance, which is going to help in the long run. This is the type of innovative thinking that has been required to address the capacity issues we are facing.” 

 In Hong Kong, WSP engineers were among the inventors of a method for building a fully functional isolation hospital from containers in just six weeks. “By using modular integrated construction, we could fabricate these containers quickly and safely off-site, allowing full inspection and fine-tuning before transferring them to the hospital site,” says Thomas Chan, executive director of building MEP at WSP. “Not only are the containers stackable, but they can also be converted into a variety of configurations for offices, laboratories and other purposes – all connectable and easily transported by sea or land.”

Further into the future, advances in such diverse fields as telemedicine, wearables, genetics and artificial intelligence will mean hospitals need to accommodate new equipment for diagnostic testing and treatments, while shortening stays or making them unnecessary for all but the sickest patients. “Now hospitals are designed around the need for longer stays in high-acuity settings like ICU and med/surg,” says Nolan Rome, leader of WSP’s US healthcare practice. “But the baby boomers are going to be the next acute care generation, and we’ve never seen a patient population that has lived healthfully this long before. We don’t know what treatments they will need. Maybe those ICUs will be downgraded in acuity to become transition beds or short-term surg beds – or even exam bays because there is more day surgery.”

In a hospital context, it is neither desirable nor economical to equip spaces for any possible future use, especially given the increasing sophistication of medical equipment. Instead, we need to consider specific adaptation scenarios upfront and design for these. “We need to be very specific about the limitations of an area and exactly what it will be able to adapt to,” says Gunnar Linder, business area manager at WSP in Sweden and a specialist in engineering healthcare environments. In Gothenburg, WSP designed a highly specialist imaging facility with a modular, demountable facade. All of the operating theatres are located around the perimeter so that one side of each room can be completely opened up to replace the bulky equipment inside. The building systems can also be sealed off, says Linder, “so you can have a construction site within a fully operational ward”.

In the light of COVID, and our heightened awareness of uncertainty, decisions that would have seemed counter-intuitive may become no-brainers. “We need to take more of a life-cycle analysis approach to resiliency decisions,” says Rome. “If a resiliency measure costs an extra 10%, does that 10% investment add value over the 50-year life cycle of the building?”

Healthcare owners rarely, if ever, sell their assets, Rome says, so they are in a good position to take a longer-term view. The US is a very competitive, cost-driven healthcare market, but providers are incentivized by government and insurance companies to reduce both length of stay and repeat visits. This has given them an added impetus to go beyond code minimum: “Most owners will do something if it’s a six-year payback or less. Anything in the seven-to-ten-year range, they will heavily consider if it helps to mitigate their risk, whether that’s infection risk or business case risk.”

WSP has been involved in several projects that take an innovative “target value delivery” approach, which breaks a project into component clusters and challenges the team to find efficiencies and added value for each cluster. This has led to greater innovation, such as prefabricated facades, but also enabled owners to clearly see where any savings from one area could be best invested in another. “If spending on flexibility or facilities can help them to reduce patient visits or operate at the same level with fewer facilities staff, then they’ll make that investment,” says Rome. “This system is helping us identify long-term resiliency paths, and really weigh and measure them so that they are accepted into the project as opposed to being value engineered out. You’re constantly doing that in real-time to make sure that you’re driving the value into your project.”

He thinks that this model also makes projects themselves more resilient. During the last market crash in 2007/08, many cash-constrained healthcare projects were put on hold for a year or more. “Now, these target value projects are weathering the storm with a little more surety and consistency because the owner understands where and why they’re spending their money. If they do have to make a reduction – because there have been three months of revenue lost due to COVID – we try to make it as shrewdly as possible and not affect the long-term outcome. If we cut something now, we may be spending twice as much money to put it back in six years from now when the building is finished.”

Target value delivery makes the case for flexibility even more compelling, and puts some numbers behind it. A hospital project may take six or seven years from design to completion, Rome points out. “Let’s say you saved 15%, if you wait until the very end to realise the savings, all you really did was lose the opportunity to invest that 15% over a six-year period. If you can bring that to the front and drive it into the value of your project, you’re using your money smarter. That’s a big investment when you’re operating on a margin below 5%.”

The built environment will always be playing catch-up in the wake of more dynamic systems. But digital technology is right at the forefront. In the next part of the series, we’ll consider how “smart” building solutions can help healthcare providers stay resilient in the face of change – and how to ensure the resilience of digital technologies themselves.