Building design trends in hospitals and health care facilities

Lessons from COVID-19 have made flexibility and resiliency top concerns when designing for hospitals and other health care facilities

By Consulting-Specifying Engineer December 11, 2023

Health care insights

  • Healthcare facilities are shifting towards outpatient procedures and advanced designs due to the demand for more sophisticated and cost-effective facilities.
  • The COVID-19 pandemic has driven changes in healthcare facilities, promoting flexible design, isolation units and improved HVAC systems to address evolving spatial needs and emergency preparedness.

November 2023 MEP Roundtable. Courtesy: CFE Media and Technology


  • John Blanton, PE, Senior Mechanical Engineer, Certus, Dallas, Texas
  • Brian Evan, PE, Associate, Wold Architects & Engineers, Saint Paul, Minnesota
  • Kristie J. Tiller, PE, LEED, AP, Associate, Director of Mechanical Engineering, Lockwood, Andrews and Newnam Inc., Dallas, Texas
  • Tim Willoughby, PE, Mechanical Engineering Principal, HDR, Omaha, Nebraska

John Blanton passed away unexpectedly shortly after responding to these questions. John’s legacy will continue to positively impact those he worked with and our industry for many years to come.

What’s the current trend in hospitals, health care facilities and medical campus projects?

John Blanton: Trends in health care continue to move toward shortening length of stay and increasing the number of outpatient procedures. As insurance reimbursement rates change for different types of procedures, so does the type of facilities we are designing and constructing.

For example, when the reimbursement rate for outpatient elective surgeries rose, ambulatory surgery centers become larger and more prevalent. With increased revenue of these facilities, surgeon requests for more sophisticated operating rooms received more attention from owners and developers. However, these types of facilities still do not typically have the construction budgets that large hospitals have. Engineers need to be more creative on these types of facilities to meet the requests for things like low temperature operating rooms (ORs) that are becoming the norm. These facilities also do not have 24/7 on-site maintenance, so the designs must consider things like reliability, redundancy and remote monitoring, within a limited construction budget.

Brian Evan: Owners are looking at the resilience and performance of their facilities. These facilities need to function through any emergency, as lives are dependent on them, so backup heating sources and power are a must. Owners are also dealing with staffing shortages, so designing efficient facilities that are easy to operate helps reduce operating costs and maintain functionality with less staff. ORs are becoming much more sophisticated, especially when robotics are involved. In order to accommodate electrical needs, space and capacity for additional isolation panels and low voltage cabinets need to be accounted for.

Kristie J. Tiller: Many hospitals are at a point now where they are no longer seeing an influx of COVID patients. This means they have the ability to strategize and use funds to begin implementing tactical measures to increase their effectiveness and safety during the next major event. Some of these measures include increased isolation units and new and improved heating, ventilation and air conditioning (HVAC) systems.

Tim Willoughby: There are three main trends I’ve seen in hospital and medical buildings. Firstly, the industry is experiencing especially long lead times for various hospital equipment. This is forcing owners to make decisions and design to be undertaken earlier to procure equipment. Secondly, increased project size and budget are making larger hospital projects more common. For example, five years ago, a hospital project was considered anything over $300 million. Today, a large hospital project will typically have a budget of $1 billion or more. Third, smart buildings/equipment and cybersecurity are more and more common. Newer hospital requirements are dictating more sophisticated controls systems, while implementing strategies that consider cybersecurity risks that are growing more prominent every day.

What types of challenges do you encounter for these types of projects that you might not face on other types of structures?

John Blanton: One continuing challenge in the design of health care facilities is balancing code and functional requirements with energy conservation. For example, ORs represent a significant portion of energy consumption due to airflow, outside air and temperature and humidity requirements. A common strategy implemented by hospital facilities managers is unoccupied setback for ORs. While adjusting the OR HVAC during unoccupied periods can save significant energy, care must be taken to maintain the required environmental conditions, pressure relationships and a sterile environment.

Operating rooms like this one have specific air pressure, lighting and electrical requirements that create challenges for engineers. Courtesy: Certus

Operating rooms like this one have specific air pressure, lighting and electrical requirements that create challenges for engineers. Courtesy: Certus

One simple strategy that minimizes risk is to adjust airflows only, maintaining a constant offset between supply and return to ensure positive pressure is maintained. With the temperature and humidity setpoints remaining constant, the relative humidity will not fall outside of the code required range. When the room is switched back to occupied, the risk of the conditions getting out of control is minimized during the transition period.

Brian Evan: Hospitals operate around the clock  and potential service outages require proper planning. Unlike school construction, which often takes place during summer breaks when facilities are relatively unoccupied, contractors may have to work during off-hours to install new equipment while existing systems remain operational. This may mean carving out a new electrical room instead of swapping equipment in the same location and extending the outage downtime.

Kristie J. Tiller: Health care design is very detailed and has specific code requirements that typical office-type buildings don’t have. Specifically, HVAC requirements are much more stringent to ensure the health, safety and well-being of patients who are in health care facilities.

Tim Willoughby: Hospitals are designated as risk category four buildings, which signifies the importance of keeping these buildings operational, even under extreme conditions. Thus, the buildings have strict requirements when designing for wind and seismic forces that they may experience. Risk category rankings affect everything from the structure to the exterior of the building to mechanical and electrical systems.

For hospital projects, there is also a huge emphasis on controlling the building systems, as well as the individual rooms during occupied and unoccupied times – requiring a more complicated design. Ensuring the rooms are functioning on the correct mode at the right time can pose unique challenges compared to those of an office building.

What are engineers doing to ensure such projects (both new and existing structures) meet challenges associated with emerging technologies?

John Blanton: Many of the technologies being applied in mechanical, electrical and plumbing (MEP) systems design in health care have been around for a long time. Some of these, including methods of dehumidification for surgery HVAC systems, are becoming more prevalent as functional and operational needs continue to evolve. Design methodology must include strategies to balance energy usage and fail safe sequences to ensure functionality of the ventilation that is still within code required parameters, even in the event of loss of power or failure of any components that are in place.

Brian Evan: In both new and existing structures, it’s important to verify the roof’s load-bearing capacity for solar panel installation. Roof obstructions like mechanical units, vents and parapets should be minimized or grouped together to maximize roof space. If roof-mounted panels are not an option, planning for green space on the site for ground-mounted solar is an alternative, however it usually requires more land than the site can accommodate. It’s also important to ensure that the main switchboard has empty conduit and a spare breaker to feed the solar panels.

Tim Willoughby: Even with emerging technologies, there is still a huge focus on resiliency in the industry. Balancing innovations with creating a reliable system requires an evaluation for the pros and cons of each system. While new technologies offer better energy efficiency or greater operational accuracy, they tend to be higher in upfront cost and require increased maintenance or higher controls complexity.

How have changes that came about during COVID-19 continued to impact health care facilities or medical campuses?

John Blanton: Post pandemic, a common design discussion is the level of filtration that should be included in the HVAC systems. However, high-efficiency particulate absorbing (HEPA) filters are costly and impose higher ongoing maintenance and energy cost to facilities that are already struggling with reduced operating budgets. Recently, we have been implementing air handling unit designs that include racks designed to accept both minimum efficiency reporting value 14 and HEPA filters. This modification in design simply changes the style of rack while maintaining the same footprint and cost. The thought process is that during the next pandemic event, a facility can simply slide out the initial final filters and install HEPA as needed. During COVID-19, to install HEPA filters in a unit that was not originally designed for them, the units had to be completely shut down for a period of time for the unit to be retrofitted with HEPA racks. Adding this flexibility to the design helps future proof the system and allows a change out of filters to happen without major shutdowns.

Brian Evan: COVID-19 played a pivotal role in the mainstream adoption of telehealth in the United States, which in turn impacted facilities as they now need the proper equipment and technology upgrades for their providers to effectively communicate remotely with patients. Additionally, it may lead to a decreased demand for physical space within facilities due to the reduced in-person appointments. The pandemic also underscored the importance of disease control, prompting a focus on sanitization and filtering, as well as new ventilation techniques to help prevent the spread of disease.

Kristie J. Tiller: The pandemic has helped identify weaknesses in campus facilities, causing owners, engineers and architects to work together to strengthen campus and health care facilities. One of the main challenges is ensuring there is flexibility in the use of spaces. The spatial needs of health care facilities are very specific, so changing the usage of each space offers unique opportunities. Engineers and architects continue to work with owners and operators to design facilities with flexibility in mind so they are prepared when the next major event occurs and can configure their facilities as efficiently as possible while maintaining the safety of both their patients and staff.

Lighting design at the new Minnesota Department of Veteran Affairs Preston Homes entry lobby. Courtesy: Wold Architects and Engineers

Lighting design at the new Minnesota Department of Veteran Affairs Preston Homes entry lobby. Courtesy: Wold Architects and Engineers


Tim Willoughby: The COVID-19 pandemic caused a shortage of manpower, which led to supply chain shortages and higher supplier and labor costs. With the pandemic seemingly under control, equipment manufacturers are playing catchup with the demand, causing longer lead times. Examples of equipment still experiencing this impact includes generators, switchgear, air handling units and variable frequency drives. Hospitals also typically aspire to develop an action plan for a possible future pandemic. The COVID-19 pandemic facilitated a knee jerk response that ranged from 100% outside air operation to makeshift treatment structures to a triage of patients that needed testing and treatment. These responses provided a “lessons learned” playbook, for approaches that did and didn’t work. We are now creating strategies that, in collaboration with our clients, provide a staged response to design hospitals for the next pandemic.

What types of smart buildings or campuses are you designing for hospital clients? Outline the automation and controls, integration and any cutting-edge technology.

Tim Willoughby: Hospital operating staff are keen to learn more information from the data that is provided by the building’s infrastructure systems. However, staff are also battling the challenge of operating a more advanced building and the ability to decipher the information to maximize hospital’s maintenance efficiency. This integration must be developed with a watchful eye on cybersecurity. The greater the flow of information, the higher the risk of potential cyber threats. To mitigate these risks, we are creating guiding principles for what needs to be done. This is a series of steps for developing a successful project. We can also partner with the owner’s IT department on how we implement this plan and developing a cyber safe system.

How are hospitals, health care facilities and medical campus buildings being designed to be more energy efficient? And, if you have experience in this area, how will new outside air requirements affect this energy efficiency?

John Blanton: For heating systems, we rarely see large steam boilers included in the design for new facilities anymore. Steam systems are costly, inefficient  and maintaining these systems requires maintenance personnel with a level of experience and expertise that many facilities do not have. Most new projects are designed with low temperature heating hydronic boilers which are much more efficient (~92%+). In addition, we are retrofitting large existing heating systems with high efficiency hydronic boilers. The existing steam systems are downsized to feed only the processes that require steam, such as sterile processing and humidification. Local steam generation for these types of loads can also be evaluated based on total life cycle cost to further reduce the demand for centralized steam.

Tim Willoughby: Hospitals operate 24/7, so the equipment must be more energy efficient than any other building. However, designing beyond code will typically have a bigger impact on energy savings due to the all-day operation. The equipment is only the first part of the equation. The second part is the control strategies and how we operate the equipment and systems. Changing the outside air requirements will demand tighter controls for these systems, while still being able to maximize the equipment and systems energy efficiency.

The inside of air handling unit shows the fanwall used to create clean air throughout a health care facility. Courtesy: Dan Schwalm, HDR

The inside of air handling unit shows the fanwall used to create clean air throughout a health care facility. Courtesy: Dan Schwalm, HDR

Looking ahead with pandemics in mind, how do you think hospitals and health care facilities will be designed? What aspects of the engineered systems will change?

John Blanton: I believe we will likely see the desire for more dedicated pandemic patient wings and overtly flexible spaces. It still is generally not practical to design a negative pressure “pandemic” floor since, outside of a mass pandemic, typical, non-infectious patient care areas should be positively pressurized to provide a clean environment for the patient. However, design of a patient floor as was done pre-pandemic does not provide the needed flexibility. Designs must be flexible to allow areas to switch to a negative pressure pandemic mode when needed. These designs require additional equipment and may require upsizing of cooling coils to handle additional outside air. Control systems and sequences will become more complex to provide a cascading airflow between staff and patient spaces so that pressure relationships are situated so air is always flowing from clean to less clean areas, regardless of the operating mode. Additional protective securities must be in place to ensure the areas are not inadvertently placed into the wrong mode.

Brian Evan: Hospitals and health care facilities will be designed with more flexibility. We saw the need to adjust either individual rooms or entire building wings to negative pressure, as well as the desire to change to more efficient filters. We found that many existing HVAC systems didn’t have the capacity for these changes. Because of this, our team is now designing new HVAC systems with increased supply fan capacity to accommodate HEPA filters. We are also sizing these systems to be able to properly heat and cool, even when a portion of the area they serve needs to change to operate under negative pressure and exhaust air directly to the outdoors.

Kristie J. Tiller: Three years removed from the start of the COVID-19 pandemic, the most significant change we see in health care facilities is the trend toward isolation units. In our projects, we see entire hospitals and most public institutions augmenting their HVAC systems. The medical facilities we are designing and renovating are increasing natural ventilation and introducing technology such as ionization to ensure cleaner air is entering and being recirculated in each space. When it comes to the expansion of Covid treatment areas, hospitals are funneling more resources and design thought to isolating pandemic patients and treating them in separate quarters to ensure the safety of others.

One such project we have performed recently is the design, construction sequencing, construction administration and commissioning services for HVAC upgrades to a northeast Texas Care Facility. This campus project will improve indoor air quality in residential homes and allow one building to be converted into a COVID isolation unit. To improve air quality, Lockwood, Andrews and Newnam (LAN) designed a fan-powered HEPA-filtered system for each of the 100 resident rooms and the 10 dining and living room areas. For the on-site COVID isolation building, LAN designed a dedicated outside air system with a permanent exhaust fan to work in conjunction with the already existing HVAC system, increasing outside airflow to each of the 10 resident rooms during isolation events. Portable, hospital-grade HEPA ultra-filtration units were also selected to be on standby operation in each residential home. In addition, LAN evaluated the existing electrical services to determine what changes would need to be made to support the new equipment.

Tim Willoughby: Based on the science of situation, hospitals can utilize “temporary” HEPA filters for systems to protect occupants. Other technologies are also being implemented to “clean” the airstream delivered to hospital spaces. Hospitals also seek to design an approach that implements a staggered response to the next possible pandemic. This could start with a couple rooms and grow to an entire patient floor.