Building most new healthcare facilities is a multi-million/billion dollar, 10 to 50-year gamble on the future.

These projects often arise because of immediate demands and proceed with such incredible cost and complexity, that it creates immense pressure on all involved.  A pressure amplified by the ticking clock of regulatory deadlines (especially in our home state of California).

High Pressure, Higher Stakes

In this environment, the seemingly safe path is to build a newer, bigger version of what exists today. Designing facilities and pouring concrete around current technologies and operational models while singularly focusing on the built environment.

But this can be a trap. This reactive approach is the single greatest risk health systems can take. It is precisely why so many healthcare facilities end up underutilized, and often times a state-of-the-art facility is in fact obsolete well before the crowd cheers as CEO cuts the oversized ceremonial ribbon.

If we really want to mitigate long-term risk and deliver ongoing value, we cannot fall into the tired trap of reinforcing the present.

Diagnosing the Real Problem

So how does this happen, you might ask?

Projects often begin with a tactical request, something like: “We need more space for administrative staff, but our campus is fully built out.” The demand for more space becomes the focus, blinding leadership to the underlying pressures that drive the need for change and obscures opportunities for future success.

When we unpack the requirements of this simple request, we inevitably find a web of systemic miscommunication, misalignment, and mistrust. We have led dozens of meetings with clinical, operational, and administrative leaders, seeing firsthand how multiple departments function in entrenched silos, rarely aligning on a cohesive strategy for future success. We are often brought in to support thoughtful facilities leaders that are tasked with solving the "space problem" and find that they are not empowered or enabled to address the lack of strategic alignment.

Often, as we lead stakeholders to dig into the "space" issue, we uncover something deeper. The shortage isn't just about square footage. It’s rooted in a tangle of outdated policies.  For instance, we have encountered cases where there is no institutional policy for remote or hybrid work, creating inconsistent expectations and allocation for where work gets done. and siloed thinking. Physicians have dedicated offices that sit empty much of the time, while clinical, operational, and facilities teams are working under their own assumptions, never convening to ask a more fundamental question: "How do we want to work in the future?"

When we realize that a space problem is a systems problem, projects must pivot. What begins as a real estate exercise transforms into a strategic conversation about operational, staffing, and enterprise demands, revealing a truth in healthcare: without strategic alignment, we are trying to solve the wrong unrelated problems. 

What can we do about it?

Addressing long-term demands in hospital design requires a fundamental shift.

Today, facility development for health systems is hit with the double whammy of (a) reacting to the problems of today and (b) the incredible urgency to complete projects as fast as possible. These issues lead to short-sighted projects, compromised facilities, and processes that fundamentally miss the broader strategic opportunities that a new building embodies.

To improve the quality of our healthcare spaces, we need to improve the quality of our healthcare systems.  We must stop solely thinking about building development, design and delivery, and start executing healthcare systems design. We should no longer be thinking about a hospital as simply a structure, but as a dynamic system, a finely tuned choreography of people, processes, and policies. The goal is to make the building a physical manifestation of the optimal state for this healthcare system.

We have an opportunity to use the mandated construction timeline as a forcing function for strategic alignment. The "go-live" date for a new building is a powerful, non-negotiable deadline, while the huge expenses and long lifetime of the building create the leverage required to bring leaders together and make complex and impactful decisions.

A New Framework for Facility Design

This new approach requires a new set of principles that ensure investments in the built environment deliver on their full potential.

1. Move with Strategic Speed: Rather than rushing into a project, we must slow down to go fast. A new facility's construction timeline provides a powerful, non-negotiable deadline. However, the huge investment and long lifespan of both ground up and retrofitted facilities provide the necessary leverage to bring leaders together and make critical decisions. This strategic engagement upfront ensures the final facility doesn't just open on time and on budget; it succeeds over the long term. This initial investment in alignment and shared vision is the most crucial product of the entire project.  In our workflow, one example is co-developing a project charter with user stakeholders, including the operational and administrative users of the facility, to ensure alignment on the long-term goals. This upfront work allows the project to be more resilient and enables the team to move faster into the future.
   
   To streamline the kickoff process, please set aside 10 minutes with your project team to complete a project charter (see this example). Even this brief exercise will help align key roles, goals, and objectives, ultimately saving time and preventing confusion down the line.
   
   There is a tremendous amount of work that goes into the facility development process, such as enterprise planning, user research, visioning, etc. To get the work launched with a small step that we all often forget, here is an exercise that might help.
   
   

2. Embrace Systems over Structures: When we embrace facility design as a ‘systems over structures’ approach, we see a new building not as a project, but as the physical manifestation of institutional strategy. In doing the unglamourous, challenging and difficult work of understanding and orchestrating the systems and interdependencies that drive long-term success of facilities, we put ourselves in a position to deliver spaces optimized for the long-term delivery of excellence in experience, care and operations.
   
   By integrating operational, business, and organizational priorities from the very start, this framework balances the concurrent pressures of healthcare delivery, unlocking latent efficiency and opportunity. Without it, the fear of investing in strategic planning becomes a dead weight on a hospital’s business, creating a critical disadvantage as market share is lost to competitors with newer, more cohesive facilities that improve the patient experience and clinical outcomes. A systems-based design is therefore an investment in excellence in patient care, securing future market position, becoming an essential differentiator for patient choice, staff recruitment and retention, and delivering tangible long-term value.
   
   To kick off this phase effectively, a valuable first step is to develop a system map of your project landscape. Start by identifying all stakeholders who will directly benefit from the project, clarifying their roles, goals, and interconnections. Next, detail their most pressing needs and objectives as accurately as you can. Any gaps in this knowledge naturally highlight areas for further systemic investigation, which is a crucial component of project planning. 
   
   

3. Design a Preferred Future: We need to proactively shape the future which will help us design resilient and adaptable healthcare facilities that stand the test of time. This proactive approach involves more than just building for today's needs; it requires a deep dive into potential futures, allowing us to explore various scenarios to identify opportunities and mitigate risks. The practice of strategic foresight allows us to build clear pathways toward a desired future, avoiding the costly and disruptive pitfalls of shortsighted planning. By anticipating future needs and challenges, we ensure that the facilities we build today can remain adaptable, integrated and valuable assets for future decades.
   
   To engage in crucial early risk mitigation, please bring your team together to fill out this speculative design worksheet. Though it involves stepping outside the usual comfort zone, this exercise will help your group collectively recognize potential obstacles and outline specific, pre-emptive steps you can take today to minimize future issues and maintain project momentum.
   
   One example or tool that you can try today is a part of a larger initiative of understanding the future called Speculative Design.  This tool, called Signals of the Future, asks your team to write down examples of transformative technological, social and economic changes occurring today and to consider how this continued development may lead to future system (see what we’ve done there) impacts, both positive and negative.

These guiding principles won't succeed without visionary leadership. This work demands champions, strategic thinkers, and executives who can see beyond their own departments and embrace an integrated strategy. It is through their collaboration that these projects are recognized for what they truly are: rare and powerful opportunities to drive organizational transformation.

So, as you approach your next facilities project, ask yourself a critical question. Will it be managed as a facilities project, or will it be led as a strategic initiative to design the future of your healthcare system?