FleXX: A Study of Flexibility in Outpatient Settings

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What is the Aim

How do we define and approach flexibility to respond to a dynamic, ever-changing present?

The future of health care, specifically ambulatory care facilities, has been widely discussed in the industry. Clinics today require the ability to be change-ready to keep pace with clinical demands and a changing marketplace.

In 2015, CADRE and JE Dunn studied drivers, trends and patient/physician perceptions around what we called “Clinic 20XX – Designing for an “Ever-changing Present” rather than a “faceless future.” From the study connectivity, flexibility, and sense of place became the core tenets of designing for change.

What do terms such as flexibility really mean and how can we approach flexibility in the design of the built environment?

Flexibility is a severely over-used word, with wide and varied definitions, often used inter-changeably with other terms such as adaptability and agility. These ambiguous definitions can affect stakeholders’ decision making, with blanket requests for ‘flexibility’. However, some levels of flexibility require strategic investment and planning, a clear ROI, and operational considerations. There is a need for an actionable framework for flexibility that can be used to inform design and structure decision making, not only for health care but all design.

To develop a framework to address flexibility in outpatient clinic settings to create change-ready facilities.


  • To understand the various definitions of flexibility and nuances of commonly used terminology.
  • To understand the need for, challenges of, and expectations around flexibility in outpatient settings from three key stakeholder groups: health care administrators, nurse managers and facility managers.
  • To synthesize current frameworks of flexibility [from within and outside the health sector] into a simpler practice-focused framework for outpatient clinics.
  • To validate this framework based on insights from key stakeholders.

What We Did

This study began by synthesizing existing literature and frameworks regarding flexibility into attributes that can be associated with space. Case studies, for both health care and analogous projects, exemplify these concepts. Finally, stakeholders were asked to provide insight based on their needs and past experiences.

The research team conducted an extensive literature scan to establish a framework for flexibility and to identify key exemplars for the various attributes. A nationwide survey was deployed, with 143 respondents, to gain further insight into outpatient flexibility, assess needs and appetite for flexibility, identify common pitfalls, and most importantly, validate the proposed FleXX framework. This survey was administered to CADRE, Steelcase Health and HKS contacts in decision-making roles for health care organizations and health care administrators, facilities managers, and nurse managers through a third-party survey provider.

What We Found

Our findings can be summarized as follows:

  • Buildings must be “flexible” in order “to” adapt. Flexibility is the affordance of the built environment that allows organizations to adapt in response to unpredictable, external drivers.
  • Versatility, modifiability, convertibility and scalability are the core attributes of flexibility. They consider user/owner perspective, affected built elements, level of ease, duration of time to change, and when/how much investment should take place.
  • Versatility and modifiability were rated the most important attributes of flexibility. They can be baked into a design solution and should not come at a premium cost.
  • Flexibility should only have a premium cost for long-term scalability – up to 20%. Stakeholders want to invest in scalable spaces.
  • The top three considerations for flexibility were amount of space, variations in sensory environment (and control over them), and ability to use the same space for different purposes/choices.
  • Flexible “stuff” (e.g. Furniture, fixtures and equipment) should be considered independently, and during space planning, as they may change a different rate than space.
  • Experience with modularity anchors on furniture – modular workstations and cabinet solutions were found more often in facilities than demountable walls, prefab exterior panels, or prefab rooms. Spaces are more likely to be modified or converted into a different function than any other spatial change.
  • Demountable walls require a systems thinking approach. Often, they are too difficult to change if they are separate from infrastructure affordances such as MEP and lighting.
  • It is not clear yet to stakeholders how FleXX ROI can be measured and over what time, even though 1-5 years seems to be a comfort zone.
  • Flexibility is not just spatially defined – it includes time, roles and resources. Adaptable organizations use building flexibility as a tool to accomplish organizational flexibility

This project resulted in a FleXX framework that can be deployed on projects to inform design and used in client discussions.

What the Findings Mean

The FleXX framework can be applied to projects to create a “FleXX Plan”, where operational strategies are planned against specific spatial modifications.

The next step for this study is to try and test the FleXX framework on real projects, and study how flexibility can not only just be planned and designed, but strategically mobilized in order to provide meaningful impact and a sustainable ROI.


Research Partners:
CADRE project supported by HKS and Steelcase Health

Steelcase Health and HKS

Team Members:
Upali Nanda
Melissa Hoelting
Jonathan Essary
Whitney Fuessel
Giyoung Park
Zach Overschmidt
Michelle Ossmann (Steelcase Health)
Seth Starner (Steelcase Health)