In this roundtable, engineers discuss current trends for health care facilities and where the industry is going in the coming years.
Learning objectives
- Identify how new energy codes and considerations are impacting the design of new and existing hospitals.
- Understand how to design for continuous operation and multiple uses across health care campuses.
- Learn how changes in the health care industry are changing design.
Health care insights
- A focus on sustainability is impacting the design of MEP systems.
- Space constraints and outdated systems make it difficult to meet new codes and standards on retrofit projects.
What are the biggest engineering trends in hospitals, health care facilities and medical campus projects?
Caleb Marvin: Cardiovascular procedures and inspections are on the rise as the population ages. Health care systems are expanding these services at their current facilities or purchasing older facilities to upgrade into dedicated cardiovascular units. In response to this specialty, the demand for uninterrupted power supply (UPS), power conditioner, generator, and air handling unit replacements or upgrades is on the rise to serve the advanced technology used in catheterization (Cath) and electrophysiology (EP) labs. The mechanical, electrical and plumbing (MEP) infrastructure to support this highly sophisticated equipment requires careful planning and coordination to help ensure optimal performance of the facility.
Brad Reuther: One big engineering trend in hospitals is a reduction in the use of steam. Maintenance staff are stretched thin, and fewer people know how to properly maintain steam systems. Condensing hot water boilers operating at lower temperatures and reduced thermal losses from the piping systems provide significant energy savings. Lower-temperature hot water systems also open the door for additional heating equipment types and energy recovery options.
Meagan Gibbs: We are experiencing a strong push towards flexibility and scalability in healthcare projects. Hospitals are moving away from static, single-purpose spaces and are instead investing in universal rooms and adaptable platforms that can pivot between acuity levels or transform into surge capacity when needed. Another big trend is the integration of research, education and care within a single ecosystem. A recent project for a cancer center we designed shows how innovation districts can create a place for scientists, clinicians and patients to be under one roof, helping to accelerate discovery-to-care pathways. Behavioral health continues to rise in prominence, with systems prioritizing purpose-built facilities that destigmatize care while improving access.
Jason Butler: A focus on sustainability is the biggest current trend in healthcare facility design.
Darren Harvey: Trends I’m seeing include electrification, microgrids, reduced overall energy usage, a reduction/removal of piped nitrous oxide systems, water reclamation, water storage and water quality. A focus on redundancy and resilience for MEP and technology systems is also common.
John Bowling: The need for additional operating rooms, cath labs and imaging equipment upgrades seems to be the largest trend in existing hospitals.
Richard Vedvik: The nation’s health care system is plagued by existing infrastructure that is beyond its useful life, often due to deteriorated physical condition, limited availability of replacement parts or overall structural wear. This trend highlights the urgent need for comprehensive assessments and upgrades to ensure operational reliability.
Jon Sajdak: One trend in the industry is the use of mass timber construction. Mass timber can support initiatives for sustainability, expedited construction schedules and aesthetic appeal. This may not be appropriate for all projects, but it is an option that has become more popular in comparison to typical steel or concrete construction. One misconception is that the wood used in mass timber construction would be dangerous since it’s a combustible material. However, mass timber has inherent fire resistance properties and should not be compared to typical lightweight wood construction. This is primarily due to charring at the surface that acts as a self-insulator to the remaining part of the member when exposed to fire.
What types of challenges do you encounter for these types of projects that you might not face on other types of structures?
Caleb Marvin: Renovations in ambulatory surgery centers (ASC) or hospitals to retrofit existing operating rooms to Cath or EP labs create unique challenges and tax existing infrastructure. Many existing ASCs were designed to meet the minimum program and code requirements for the original design, often within a tight budget. Existing generators at these facilities may not be sized to handle the additional electrical load of the equipment. Replacing the existing generator or adding capacity creates complications with the existing distribution that need to be identified early in a project. Many facilities do not have a UPS, which is required to protect the patients in the event of a loss of the normal systems. These systems require a lot of space and reject a lot of heat that must be accounted for.
Brad Reuther: A significant challenge for many healthcare facility types is the need for continuous operation. Renovation projects often involve complex phasing to be incorporated into the design. This may involve temporary relocation of some functions to create an empty chair where construction can start and progress area by area until the renovation is complete. Phasing boundaries must take into consideration patient care functions, infection control, life safety, construction logistics and the availability of MEP systems to provide the required services at each stage. These projects often benefit from early contractor involvement to reduce the risk of surprises during construction.
Meagan Gibbs: Hospitals are some of the most complex building types to design. Unlike a corporate office or school, hospitals operate 24/7 and must maintain critical systems with zero downtime. That means design and construction phasing, infection control risk assessments and redundant utilities are part of every project. Hospitals carry unique regulatory frameworks, including Facility Guidelines Institute recommendations to Joint Commission requirements, that demand precise compliance. Health care projects also involve highly integrated systems: MEP, structural, IT, medical equipment and operations must be coordinated precisely. The engineering challenge is less about designing isolated systems and more about ensuring an entire ecosystem functions reliably under constant demand.
Jason Butler: The myriad of codes, standards and regulatory bodies is a challenge for health care projects, as well as the overriding emphasis on reliability and patient/staff safety.
John Bowling: For medical gas systems, we sometimes find that vacuum systems do not meet current waste anesthetic gas disposal requirements.
Darren Harvey: Hospitals are most often owned by the operators and are constructed for a 50-year lifespan. The desire for more redundancy and resiliency in a hospital facility often challenges both the initial budget/quality of systems and operational budget needs. A balance of both is often needed to have a successful outcome. Space and infrastructure planning for future systems can be an effective approach to maintain the initial project budget.
Richard Vedvik: As the health care system expands or remodels departments, the existing infrastructure is commonly left out of the early budgeting process. This oversight leads to significant issues, such as unforeseen costs for essential upgrades to MEP systems. Unlike other structures where infrastructure might be simpler, health care projects demand uninterrupted operations, making phased implementations complex and requiring careful coordination to avoid disrupting patient care.
Jon Sajdak: Opening protectives and the treatment of penetrations are some of the primary challenges that are present in health care facilities. Health care occupancies have numerous fire- and smoke-rated assemblies, including but not limited to smoke barriers, fire barriers and smoke partitions. Each wall type has specific opening protective and penetration requirements, which must be closely coordinated during design and installation. Doors and windows in these assemblies are required to have specific ratings, fire and/or smoke dampers and penetrations that must be sealed. Firestop systems are commonly used for treating penetrations and are required to have specific F and T ratings.
What are engineers doing to ensure such projects (both new and existing structures) meet challenges associated with emerging technologies?
Caleb Marvin: Proper planning when designing these types of spaces is crucial. The design engineer must study the existing electrical distribution system from the generator to the main distribution panel planned to serve the equipment. The equipment for cath and EP procedures requires a significant amount of power added to the distribution. A load study consisting of metering described in NFPA 70: National Electrical Code Article 220.87 and power quality assessment should be performed to verify existing demand and ensure that the existing infrastructure can support the additional loads. Along with the higher electrical demand, the equipment also requires significant cooling. Pretesting of existing HVAC systems is often needed to determine available capacity as the engineer plans required upgrades to support the new equipment.
Brad Reuther: Health care facilities are in a constant state of change as new treatment methods are developed and technology advances are implemented. Older existing facilities require creative solutions and different system considerations to overcome constraints such as tight floor-to-floor heights. New facilities can be designed with systems sized with spare capacity and flexibility to accommodate changes in space use or equipment. Equipment rooms can also have extra space or be designed to expand if additional equipment is needed.
Meagan Gibbs: The pace of technology adoption in health care is accelerating. Robotics, AI-enabled diagnostics, real-time location tracking, telehealth and immersive training all place new demands on infrastructure. Our approach is to design flexible, high-capacity backbones into facilities. Designing robust data and electrical distribution systems that can support both current needs and unanticipated future technologies without major renovation is essential. In existing buildings, it is important to implement modular infrastructure upgrades, such as universal cable pathways and adaptable mechanical systems, so that facilities can absorb technology without disruptive downtime.
John Bowling: For existing hospitals, during our schematic design phase, we identify systems that may be at the end of their useful life. Usually, the client will recognize that a controlled changeout is better than an unplanned shutdown if the equipment fails later. These are ideal times to evaluate new technologies. For greenfield hospitals, most owners are hesitant to apply new technologies that do not have a reduced initial cost or if they complicate the maintenance of the solution.
Darren Harvey: Emerging technologies can be challenging from several standpoints, including allocating budgets for systems that aren’t fully understood or often implemented, understanding the responsibility matrix for these systems, building emerging technology systems without hitting proprietary infrastructure needs that drive up costs, getting the systems to operate correctly and implementing training before seeing the first patients. Collaboration between the owner, design professionals, vendors and installing contractors is crucial during the design, installation and systems startup phases to make sure the new technologies are successful. This collaboration leverages the lessons learned across multiple entities.
Richard Vedvik: Engineers should be consulted during the programming and planning phases of a project to ensure necessary infrastructure upgrades are accounted for in both the project budget and project timeframe. When an engineering team has historical knowledge of the campus, they are an essential part of the healthcare team, helping establish equipment replacement priorities.
What types of smart buildings or campuses are you designing for hospital clients? Outline the automation and controls, integration and any cutting-edge technology.
Brad Reuther: Advancements in controls and integration capabilities provide increased ability to monitor, analyze and adjust building systems to maintain patient and staff comfort while also optimizing energy efficiency. The building automation system (BAS) can bring together data from various systems such as HVAC, plumbing, lighting, power, fire alarm and security. Software packages can then analyze this data to automatically identify, diagnose and prioritize operational faults within building systems. This can help building operators address problems quickly before they result in additional issues. Energy management information system software packages take this a step further with data visualizations, utility data analysis, automated optimizations and operations and maintenance process improvements.
Meagan Gibbs: Smart hospitals are becoming a new benchmark. We are deploying automation systems that integrate patient tracking, asset management, energy controls and predictive maintenance into a single digital platform. When designing a Midwest hospital’s recent expansions, we incorporated Internet of Things-enabled systems that allow real-time monitoring of energy use, room conditions and clinical workflows. This data can be used to improve efficiency and patient experience simultaneously. We are also embedding AI-ready infrastructure into new projects so that analytics can drive operational decisions, from patient throughput to energy optimization.
Jason Butler: There is definitely a need for facilities to streamline their building operation. One strategy is increased controls, automation and intelligent fault diagnostics. A driver of this is the deficiency of employment in facilities, as well as the pipeline, much like the engineering industry as a whole. The challenge for many facilities is that the existing control systems often need significant upgrades to realize the benefits of these smart building strategies, and the price tag of those upgrades often presents a barrier to getting initiatives like that approved and funded.
Darren Harvey: We are once again seeing an interest in energy optimization, digital twins and automated fault detection and diagnostics, so hospital owners/operators have somewhat of an automated way to keep their facilities running smoothly without a large increase in facilities personnel labor needs.
Richard Vedvik: Virtually all modern buildings are equipped with networked systems for lighting, building automation and building security. Health care buildings are adding digital signage. As AI integration into BAS increases in functionality, we can expect massive improvements in building energy savings as temperature setpoints are coordinated with predictive occupancy.
How are hospitals, health care facilities and medical campus buildings being designed to be more energy efficient?
Caleb Marvin: Hospitals require large volumes of air to meet the air change per hour requirements. The largest air requirements in a hospital are serving operating rooms. Surgery departments demand large amounts of energy to maintain the sterile environments. To help offset the peak demand and improve energy performance, scheduled airflow setback can be implemented to reduce the airflow in the operating rooms when not in use. Return air valves or motorized dampers restrict the return airflow during these modes, maintaining positive pressure in the sterile environment. The normal operation can then be enabled by occupancy sensors in the operating rooms or building automation overrides. When designed and operated properly, this setback strategy can result in significant energy savings while maintaining required ranges for space temperature, relative humidity and pressurization at all times.
Brad Reuther: Energy reduction strategies require a holistic approach as they vary by facility type and climate zone. Building envelope, lighting and plug load improvements save energy and reduce mechanical loads. Mechanical system energy savings strategies are implemented on many levels. Airside energy recovery reduces peak cooling, heating, and humidification loads. Reheat can be reduced by decoupling ventilation from space cooling, supply air temperature reset, and occupancy controls. Fan energy is lessened by reducing velocities in air handling units and duct distribution. Central plant energy is reduced with highly efficient equipment and by taking advantage of waste heat through energy recovery using heat recovery chillers and domestic water preheat. Building commissioning and implementation of energy management control systems ensure that systems are operating correctly and allow for optimization based on actual operating conditions.
Meagan Gibbs: Health care is inherently energy-intensive. However, we are making significant strides. High-efficiency HVAC systems, heat recovery chillers and electrification strategies are leading the way. On a recent healthcare project, we designed systems that reduce energy use intensity well below national baselines while maintaining resilience and reliability. Additionally, another hospital project in the Midwest, currently under construction, is an electrified building using heat recovery chillers and electric boilers. For humidification, in lieu of steam, we have implemented adiabatic humidification, which takes cold reverse osmosis water and atomizes it into the airstream by high-pressure nozzles. We are also seeing greater use of renewables and microgrids in campus settings, where hospitals are adopting district energy models to optimize performance across multiple facilities. Importantly, sustainability goals align with resiliency. Systems designed to reduce energy consumption also improve reliability during peak demand or outages.
Jason Butler: The most notable trend is the focus on both carbon reduction and energy use reduction. Increasing energy efficiency has been a goal of health care facilities for some time, mostly to reduce operating costs, but a lot of the strategies that have been employed in the past have mostly been low-hanging fruit. Particularly, hospitals are facing challenges in making significant strides due to the age and condition of many existing facilities. However, the equipment and technology advances are accelerating, and the healthcare industry as a whole has made significant efforts to take the necessary steps towards carbon neutrality.
John Bowling: We try to make an effort to require BAS contractors to set up energy dashboards as part of the graphics. This makes it easier for the end-user to track overall efficiencies of the equipment being controlled. It takes a little more design time, but I think we owe it to the clients to provide them with a better return on the investment in the BAS. This can usually be done without the client having to subscribe to a service.
Darren Harvey: Energy codes continue to raise the bar on what’s required for energy efficiency, which in turn drives product development and quicker adoption and implementation of these evolving technologies. We’re seeing heat pump chillers commonly used to transfer waste heat from the cooling cycle into the heating system and/or domestic hot water systems.
Richard Vedvik: The HVAC systems in modern hospitals are increasing in energy efficiency while incorporating redundancies for pandemic modes and equipment maintenance. While systems like chilled beams and variable refrigerant flow are options for medical office facilities, traditional hydronic reheat variable air volume systems are still primarily used due to their reliability and controllability.
What future design challenges do you anticipate related to hospitals or health care facilities?
Brad Reuther: While decarbonization is a significant challenge for hospitals and health care facilities in the future, it is also a major opportunity to upgrade to more efficient systems. Health care facilities, especially hospitals, tend to be cooling-dominant systems with a plentiful supply of waste heat. Reuse of waste heat is an essential tool to minimize the need for increased electrical system capacity. Transitioning to low-temperature heating hot water allows for the implementation of dual-purpose high coefficient of performance heating and cooling equipment. The addition of ground source loops or other types of thermal storage provides a means to reduce peak HVAC electrical demands.
Meagan Gibbs: Looking ahead, two challenges stand out. First, the convergence of health care and technology is accelerating, which means facilities must be designed for adaptability at a scale we have not seen before. The traditional 50-year hospital model will not keep up if infrastructure cannot flex to new modalities of care. Second, the push toward decarbonization will reshape health care engineering. Hospitals will need to achieve aggressive carbon reduction targets while still maintaining mission-critical resilience. Balancing sustainability with 24/7 operations, especially in older facilities, will require new strategies in electrification, energy storage and systems integration. These challenges are significant, yet also represent the next frontier of healthcare design innovation.
Jason Butler: The continued migration of low acuity services out of hospitals, to outpatient environments, has heightened the need for flexibility and adaptability. Building infrastructure systems must be able to accommodate the changing needs of spaces, whether that is non-clinical space being converted to patient care, or patient care being upgraded for higher acuity care. The entire building infrastructure needs to anticipate needing to change over its lifespan.
At an industry level, the major strategic challenge for most organizations will be achieving net zero energy and carbon, especially organizations that have a significant portfolio of existing (aging) facilities.
Darren Harvey: The increasing technical complexity of hospital MEP and technology systems requires an increasing operator level of knowledge to keep the buildings operating as intended. Commissioning was introduced as a mainstream need about two decades ago to get the hospital systems up and running as intended. It feels like we’re now getting to the next level, where continuous monitoring and analysis of these complex operating systems is necessary. Resiliency infrastructure in a well-run health care facility can often be reduced by a well-managed facility, as compared to the historical approach of providing entirely duplicate (N+1) infrastructure in case of a failure.
Richard Vedvik: Electrification of hospital campuses will be challenging as the infrastructure is not capable of powering electric heating systems, especially where those systems are required to be on the essential electrical system. This shift demands significant upgrades to electrical grids and backup systems to handle increased loads without compromising reliability during emergencies or peak usage periods.
Jon Sajdak: Hospitals and health care facilities are constantly adapting to new technologies, advancements in equipment and pushing to improve patient experiences. Therefore, the flexibility of transitioning spaces based on patient needs will be critical to optimizing functional space in health care facilities. During design, it is important to consider both day one requirements and potential future configurations to promote operational flexibility. One example we recently saw firsthand during the COVID-19 pandemic was the need to quickly convert areas of health care facilities into dedicated treatment areas, with specialized negative pressurization to limit infectious spread into adjacent areas.
