Healthcare Architecture as Infrastructure

Open Building in Practice

Stephen H. Kendall, Stephen H. Kendall

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351256384
• Edition: 1
• Topic: Architecture
• Subtopic: Architecture General

Architects and healthcare clients are increasingly coming to recognize that, once built, healthcare facilities are almost immediately subject to physical alterations which both respond to and affect healthcare practices. This calls into question the traditional ways in which these facilities are designed. If functions and practices are subject to alteration, the standard approach of defining required functions and practices before acquiring facilities is obsolete. We need other starting points, working methods, and ways of collaborating.

Healthcare Architecture as Infrastructure presents these new approaches. Advocating an infrastructure theory of built environment transformation in which design and investment decisions are organized hierarchically and transcend short-term use, the book draws the practice and research of a number of architects from around the world. Written by experts with experience in policy making, designing, building, and managing complex healthcare environments, it shows professionals in architecture, engineering, healthcare and facilities management how to enhance the long-term usefulness of their campuses and their building stock and how to strengthen their physical assets with the capacity to accommodate a quickly evolving healthcare sector.

Chapter 1

An infrastructure model of the building stock

Stephen H. Kendall

A significant literature exists in many fields – including economics, business and engineering – addressing infrastructure in the built environment (Ainger and Fenner, 2014). Road networks at different scales, railway lines and irrigation systems come to mind, as do potable water and sewer systems and communication networks. They all serve multiple users and frame physical conditions for inhabitation and use. These are large capital assets whose design and use stretch over large territories and continue in operation over long periods of time, and whose parts are incrementally upgraded while the whole system remains in operation. Control of their design, construction, use and adjustment is distributed and guided by both deep cultural conventions and coercive regulations. Governmental entities as well as private parties and, in recent years, public-private partnerships are involved in complex and changing patterns of initiative, financing and management of such infrastructure.

From the perspective of design, construction, management and use, infrastructure depends on the use of a hierarchy of “levels” of intervention. These levels are related to each other in a particular way. That is, a “higher level” constrains “lower levels” which can change or be replaced without causing higher levels to shut down or be altered (Habraken, 1998, 2002). In a transportation system, a highway is such a “higher level” offering capacity for “lower level” physical systems – i.e. vehicles of certain kinds. There are other relations between levels. For instance, highways are located in and funded by political jurisdictions, with all the negotiations and evolving standards we are familiar with, but are then occupied by private vehicles, new versions of which are regularly introduced. Highway construction and automotive standards and regulations are also distinguished according to levels, as are the specialists designing, financing, building and maintaining them. The clarity of these “levels,” their interfaces and disentanglement lends infrastructures longevity at the same time that they enable incremental renewal.

Increasingly, large buildings serving multiple and changing users show similar characteristics by offering space for customized user settlement. Shopping centers and office buildings, for instance, have behaved this way for more than a half-century. We also see residential buildings (Kendall, 2017; Kendall and Teicher, 2000), hospitals (Kendall et al., 2014), and educational facilities (Dale and Kendall, 2018) shifting toward this mode. For everyday users, such buildings are experienced as “whole” artifacts – the building as entirety or the space occupied as a unity – yet the processes by which they come to be and transform follow a levels or infrastructure model.

Aside from important questions of architectural quality and the enduring and deep resonance of a building or place with its local culture, the implications for regulation, financing, policy making and for innovation in the building industry are important.

Base Buildings: a new infrastructure

In large buildings, we are seeing a tendency to separate a “Base Building” from “Fit-Out” and “Fit-Out” from “FF&E” (fixtures, finishes and equipment). This separation into three “levels” is also known by other names, but whatever the words used, the distinctions are increasingly conventional – internationally – and are mirrored in the real property and building industries’ practices, methods and incentive systems.

For example, commercial office buildings use these distinctions, internationally. Tenants lease space in buildings in which the layout for each is custom designed and individually adaptable over time, and in which furnishings and equipment are updated frequently. Private and governmental institutions owning (or leasing) large buildings likewise make these separations to accommodate ongoing relocation, reconfiguration and re-equipping of functional units. Large architecture, engineering, construction and product manufacturing companies have distinct divisions to service the design and construction of Base Buildings. Other companies operate exclusively at the level of the Fit-Out; some design, produce and install proprietary product service solutions (Morelli et al., 2018; Yu and Sangiorgi, 2017); still others concentrate on equipment and furnishings. Tenants own or lease Fit-Out partitioning and equipment, and if they own it, can sell it to the next users, or may clear out the space when they leave, increasingly aided by parts prepared for disassembly or recycling, or sold into a secondary market as part of a circular economy (McDonough and Braungart, 2002), leaving spaces to be fitted out anew by the next occupant.

Another example is shopping malls, either free-standing or incorporated into mixed use developments, including airports. Developers – public, private or public-private partnerships – build large structures giving attention to public or common space and functions (such as parking and public facilities, etc.) and shared utility systems. Retail space is left empty. Overall architectural, technical, space and signage standards are established and documented in detailed tenant handbooks that themselves are periodically updated. This enables retail chains to lease space and bring in their own designers and Fit-Out services in a process that enables rapid turnaround of space for new occupancies, without disturbing the longer-lasting and shared infrastructure, public space or neighboring users.

This way of constructing and using built space constitutes a substantial market, which, in turn, has given rise to increasingly profitable and well-organized supply chains serving the demands for tenant “Fit-Out” (Kendall, 2013). All decision levels include finance companies, product manufacturers, design and engineering firms, construction companies, equipment suppliers and a host of others.

There is good reason to believe that innovation in services, products, finance and management has flowered because of this model, because it is easier to innovate on parts of a complex system when the “whole” system is disaggregated or “de-integrated” (but held together by smart agreements and interfaces), as in any well-functioning infrastructure.

Why has this trend emerged?

The emergence of this phenomenon lies in a convergence of three dominant characteristics of everyday contemporary built environment. First is the increasing size of buildings, sometimes serving thousands. Second is the dynamics of the workplace and the marketplace where use is increasingly varied and changing. Third is the availability of, and demand for, an increasing array of equipment and facilities serving the inhabitant user. In that convergence, large-scale real estate interventions make simultaneous or unified design of the Base Building and the user level impractical. User-level decisions are effectively deferred and inevitably change over time in any case, in big and small ways. This is what drives the very large and growing remodeling and renovation sector of the building industry, which now includes vertically integrated companies. Social trends towards individualization of use make functional specification increasingly personalized and changing. Greater complexity and variety of places of work, healing, commerce, dwelling and education demand adaptation by way of architectural components with shorter use-life, such as partitioning, ceilings, bathroom and kitchen facilities, specialized equipment, and so on.

This separation of Base Building from Fit-Out, and Fit-Out from equipment – observable everywhere in the world while using diverse terminology – includes utility systems as well. Adaptable and accessible piping, air handling and wiring systems on the equipment and Fit-Out levels, for example, connect to their counterpart and more fixed (“higher level”) main lines in the Base Building, many of which connect to the next higher level infrastructure serving a district, an entire city or region. Here again, control is distributed hierarchically, not unified; for practical – if not political – reasons it would be very unusual for one party to control all levels. In this process we see a significant contrast between what is to be done on the user level on the one hand and what is understood to be part of the traditional long-term investment and functionality of the building on the other.

This is the reason for the emergence of the Base Building as a new kind of architectural infrastructure.

The distinction here is best understood as happening between “levels of intervention” as is always the case when we compare infrastructure with what it is serving. In the case of buildings, the comparison has multiple dimensions, including the following:

BASE BUILDING	INFILL or FIT-OUT
Longer-term use	Shorter-term use
Shared-service related design	User-related design
Heavy construction	Lightweight components
Long-term investment	Short-term investment
Equivalent to real estate	Equivalent to durable consumer goods
Long-term financing	Short-term financing

Hospitals are evolving in similar ways

Application of this distinction is now evident internationally in healthcare facility construction, as the chapters that follow show. More than any other building type, hospitals are functionally diverse and technically complex. Changes in demographics, diseases and their treatment, equipment, doctors’ insights and preferences and regulations are forcing the emergence of a shorter use-life Fit-Out level, corresponding directly to healthcare functions which are the basis for the fiscal management of healthcare organizations. The Fit-Out level is again usefully distinguished from the even shorter life of equipment and furnishings.

When this distinction is recognized, construction of medical Base Buildings can start before detailed Fit-Out design has been finalized, allowing a substantial shortening of the project critical path. Currently, it is not exceptional that a five- to seven-year period elapses between initiating the planning process for a large medical facility and start of operations. Much of that time is normally spent determining the specifics of what we can call Fit-Out and equipment, during which time overall design is typically on hold. The evidence is that departmental requirements (e.g. surgery, pediatrics, laboratories) and equipment specifics evolve during the design phase in any case, and are to some extent obsolete when the building is first occupied. If a Base Building is conceived of as a project by itself, construction can commence and functional layouts and equipment acquisition can be deferred, without disturbing the construction schedule of the Base Building. There is already a distinction of this kind in the procurement of healthcare facilities for the United States Defense Health Agency called Initial Outfitting and Transition (Initial Outfitting and Transition) (US Army Corps of Engineers, 2017).

Some hospital clients also build “shell” or “soft” space which they later Fit-Out or leave empty for use when the building must be changed and functional units redistributed or resized. In such cases, it is not uncommon that different firms are hired to design the Base Building and the Fit-Out of the building and still others to specify and install the equipment. While commencing a complex project without having all of the details known might appear to increase risk, the opposite is evident: using infrastructure principles helps manage uncertainty, and reduce risk to investors, users, and service providers designing, building and managing complex medical facilities.

Some implications of adopting an infrastructure model of buildings

In the literature on real property and real estate, real property assets including healthcare facilities are usually described as what I would call “lumpy” assets (Geltner and de Neufville, 2017). They are seen as largely indivisible or unitary economic entities, to be juggled and moved as “wholes.” The adoption of an infrastructure or “levels of intervention” model of the building stock reveals the actual granularity – or deeper hierarchy of “wholes within wholes” – of built environments. (Habraken, 1998, 2002) (See Figure 1.1).

Figure 1.1 A levels of infrastructure model of the built environment.

The use of levels, evincing territorial/hierarchical depth, can, but need not, result in a shift from unified to divided control. A single party may still control all or several levels in this model, with the consequence of centralizing risk and expanding the management responsibility of the single party. For instance, one party can control the Base Building, Fit-Out, and furnishings. Frank Lloyd Wright was not alone in demonstrating a propensity for an architecture of unified control.

But using levels also enables control distribution to be managed, rather than avoided. This is evident when the design control of an urban tissue belongs to an urban design firm, while design of individual buildings is distributed to different design firms. Another example is when part of a real property asset is owned by one party (or the collective of individual owners), and the many spaces served by it (or that occupy it) are each controlled by independent parties. This can happen either through distributed ownership as in condominiums, through leasing or “granted rights” agreements, or in the case of individual departments of an organization such as an academic medical center, when each functional unit may serve as a decision unit or profit center.

Divided or distributed control – either through separated contracts or in unified contracts mandating clear separation of activities – produces interfaces and the need for clear agreements (Emmitt and Gorse, 2009). But tacit interfaces exist in any case, even in situations of “integrated” control, between designer and builder, or between client and designer where a handsha...