A retrospective analysis of space planned for selected clinical areas in acute health care facilities between the years 1980–2008 was conducted. Findings revealed that, during the 28-year period, incremental growth occurred in both room size and departmental square feet in adult inpatient units as well as interventional services. This observed growth and—in many instances—super-sized or excessive growth may be attributed to various factors, depending on the year of construction, regional variability or level of urbanization. However, at a macro level, growth may be attributed to changes in patient care and operational models; consumer-driven health care and market competition, demographics and patient acuity, technology and regulations and building codes. In the future, forces including but not limited to capital availability, an increased desire for efficiency and continued escalation in the cost of construction are likely to play an increasing role in offsetting the desire for sizing excess.


The term “super-sizing” was first introduced by the fast-food restaurant McDonald’s; it referred to the act of making something better by increasing its size. Over time, the term has lost much of its positive connotation and has become popularly associated with an unappealing cultural desire for excess. The health care industry is not exempt from this phenomenon and has witnessed its own version of “size creep.” This observation has critical implications within the health care field, given the desire and commitment of hospitals and health care systems around the United States to expand or renovate their facilities. Current estimates suggest that the health care construction industry is engaged in $47 billion worth of ongoing construction (Carpenter, 2008). In terms of the delivery of care, facility sizing affects not only the patient experience and the ability and ease with which caregivers work, but the technology requirements, operational costs and, ultimately, the allocation of limited capital resources.

Using 76 archived projects from nearly 30 years of client work, this analysis provides insight into the evolution of one management consultancy’s sizing standards and illuminates specific sizing trends (Kurt Salmon Space Programming Database, 2008). Conclusions are drawn about the observed growth and what can be considered justifiable versus unjustifiable, as well as some of the factors driving this expansion in programmed spaces. The paper concludes with a discussion of potential anti-super-sizing forces moving forward in the 21st century as well as the implications if this observed super-sizing phenomenon continues. Ultimately, this paper attempts to answer the question: “Have we gone too far?”

Projects Included in the Study

This study includes a national sample of 76 hospitals, programmed over a 28-year period from 1980–2008 (Table 1). The sample includes hospitals varying in size from small community hospitals to large quaternary academic medical centers. Specific department sample sizes include: adult critical and acute care services (n = 51 facilities), interventional services (n = 62 facilities) and imaging services (n = 27 facilities). Imaging services were narrowed to the 10-year range from 1997–2008. These three areas were selected for analysis because of their relative consistency across internal programs, in addition to the fact that they comprise the vast majority of “repetitive elements” in hospital planning projects. Other equally important areas were less consistent in occurrence and application, leading to difficulties in assembling a statistically significant sample for study.

Data Collection

A retrospective analysis was conducted, which identified key clinical areas of interest within the adult inpatient setting; all children’s hospitals were excluded. Space programs for adult inpatient, interventional and imaging services were compiled and reviewed from the client database of programmed facilities of a national and international consultancy to health care organizations. Programmed values were manually transcribed and data analysis was conducted using Microsoft Excel. The following metrics were applied to all programs:

Net square feet (NSF) represents the physical floor space available within a room or area for a given function or use. It is measured from the inside, wall-to-wall or to the lines of functional separation. In some cases, the “net area” will be enclosed by partitions and a doorway, while in others, net area will be a portion of another room or space. Net area determinations are based on functional need, measurements of equipment, manufacturer recommendations and experience.

Departmental gross square feet (DGSF) includes the sum of net square feet plus an allowance for walls and partition thickness, as well as corridors that are specific to the department. DGSF is measured from the inside face of exterior walls to the corridor side of corridor walls to the center line of common walls being shared with another department.

The DGSF includes all corridors that serve only a single department, but it does not include any corridors that serve more than one department.

The DGSF includes all structural elements within a department, but it excludes major mechanical and circulation shafts running through the department, unless the stair or shaft is dedicated to that department.

Toilets, housekeeping closets and other support spaces dedicated to a department are included in the DGSF.

Net-to-gross multiplier is applied to the sum of all departmental NSF that calculates DGSF. These multipliers are empirical and based upon national norms as well as the experience of this health care consulting firm which is experienced in the programming of space requirements. They vary by department depending on the intensity of small rooms and the required widths of corridors.

Building gross square feet (BGSF) includes the sum of all DGSF plus allowances for stairs, elevator shafts, mechanical and electrical equipment rooms, building lobbies and public spaces, entry canopies, common toilets and other nonprogrammed areas. BGSF is the sum of the floor areas included within the outside faces of exterior walls and pertains to all stories or areas that have walkable floor surfaces and a head-room height of at least 6′ 0″.

Note: When programming buildings with large public mall or lobby spaces, it is necessary to include these spaces as programmed (i.e., net) area and not as part of the building net-to-gross factor.

Departmental-to-building (DGSF to BGSF) multiplier is applied to the DGSF during the programming phase. This multiplier can vary widely based upon several factors but includes all major mechanical, electrical and plumbing, as well as building vertical and horizontal circulation. For new buildings, it is most dependent on the actual design configuration, and the standard industry planning range is 1.3 to 1.4. However, for small high-tech projects or other equipment-intensive situations, it may be higher. In the case of renovation projects, the existing building configuration must also be considered.

Note: When programming hospitals, it is necessary to include the central energy plant in the programmed area and not as part of the building net-to-gross. All other mechanical/electrical/plumbing (MEP) is included.

Note: Historically, information technology (IT) rooms (i.e., network closets) have been captured in the DGSF-to-BGSF multiplier; however, these requirements have grown significantly in the past 15 years. The issue of where to count IT infrastructure rooms that are not dedicated to a department continues to be debated. However, because IT spaces have become a substantial element of modern health care facilities, they are most often programmed space (i.e., net) and not subsumed into the BGSF multiplier.

Ultimately, the type, quantity and optimal size of elements for a new space are all included within a space program. The number of individual units is then multiplied by a unit of net square feet to reach a total square footage. An example of a space program is presented in Table 2.


Programming terminology has varied greatly over the years, both within the industry and between institutions. Given the noticeable discrepancies in programming nomenclature by year, region, and hospital, the following definitions for room types and clinical departments were applied to all programming documents reviewed to determine their relevance and inclusion in this analysis.

Adult acute care unit (DGSF) includes specialized and general medical/surgical, telemetry/step-down/progressive, acuity-adaptable and/or universal adult inpatient units. It excludes subacute units (e.g., rehabilitation, psychiatry and geriatrics), obstetrics, general or specialized pediatrics, research and observation units. It includes direct patient care and unit-based support. It excludes clinical support satellites (respiratory therapy, biomedical engineering, rehabilitation services, pharmacy, social services and clinical dieticians), unless dedicated within a specific unit.

Adult acute patient care room (NSF) includes patient room, toilet and bath/showers. It excludes hallway documentation stations if they are listed as a separate line item. Semiprivate rooms were counted as multiple-occupancy rooms (i.e., four patients in a 400 NSF ward equals 100 NSF per bed). It excludes isolation anterooms.

Adult critical care unit (DGSF) includes general and specialized medical/surgical intensive care units. It may include acuity-adaptable or universal units, if they are designated as critical care. It includes direct patient care and unit-based support. It excludes clinical support satellites (respiratory therapy, biomedical engineering, rehab services, pharmacy, social services and clinical dieticians) unless they are dedicated within a specific unit.

Adult critical patient care room (NSF) includes patient room and toilet. It excludes isolation anterooms.

Interventional services (DGSF) includes the surgery department and all direct support. It may include interventional or image-guided suites, clean or minor procedure rooms, perioperative services and clinical support (e.g., anesthesia workroom, biomedical engineering satellite, as well as pharmacy and frozen section/surgical pathology), direct administration and staff support. Spaces excluded in the majority of cases include preadmission testing clinic, faculty/physician offices, central sterile, and satellite clinical laboratories.

Operating room, major and interventional (image guided) suite (NSF) includes operating room and interventional procedure room, control room and/or computer room. It may include cardiac catheterization, electrophysiology and interventional radiology. It excludes minor procedure rooms, gastrointestinal/endoscopy, bronchoscopy, cystoscopy (unless sized as an operating room) and C-section operating rooms. It excludes sterile core, substerile areas, scrub sinks, and preparation/recovery stations.

Imaging services (DGSF) includes various modalities (general radiography, fluoroscopy, ultrasound, interventional radiology, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), nuclear medicine, mammography, bone densitometry, cardiodiagnostics, neuro diagnostics), direct clinical support, administration and staff support. Older programs may include significant film storage. It typically excludes faculty/physician offices.

Imaging room (NSF) includes procedure room, control and/or computer rooms.

A Retrospective Study: Hospital Sizing 1980–2007
Findings: Grossing Factors

Department size has increased because of the need for more circulation space; this is, in part, responsible for growing NSF to DGSF multipliers.

Total facility size has increased because of growing DGSF to BGSF multipliers, accommodating growing requirements for public space, mechanical systems, and information technology.

Limitations of the Study
One Data Source

Only projects programmed by this international and national health care consultancy were used, thereby introducing bias from sample selection, which ultimately may influence the validity of the findings as well as their applicability to other firms’ and institutions’ work. All interpretations of this study’s external validity should be used with this caveat in mind.

Absence of Built Data

This analysis reflects a review of the mathematical sum of programmed departments; however, the physical, geometrical and built size of these departments (and institutions) was not investigated. Ultimately, the space recommendations listed in the programming documents may differ from the final built environment. Anecdotally, budgetary issues and the like sometimes result in the program experiencing a “reduction of all rooms by 10%,” an approach which this health care consulting firm does not recommend. Likewise, in the case of specialized architectural design or configuration, the building could grow by 10% or more beyond the program.

Small Sample Size and Incomplete Data

Similarly, the small sample size (N = 76) introduces a certain degree of bias. Moreover, the incompleteness of the data resulting from nonstandard documentation in the archived space programs (e.g., NSF was provided but DGSF was not and/or data were not available from the years 1992–1995) rendered a portion of the sample unusable.

Variability of Programs

Data included two major program types: full replacement facilities and major additions. Select programs included renovations within an existing facility. A number of other institution types were also incorporated into the analysis, including community and teaching hospitals as well as academic medical centers; however, the study excluded all children’s hospitals. Given the variability in both the types of projects and facilities included in this analysis, it is impossible to state categorically that the trend observed (and its strength) can be generally and universally applied to all inpatient settings.

Variability Between Programmers

Intraprogrammer variability was also observed. However, whether this effect is the result of the individual programmer’s style/preference, the result of a client request or a combination of the two is indeterminable. Additionally, the magnitude of this phenomenon is unknown, which underscores the importance of understanding the historical context associated with the respective programs. Similarly, the grossing factors used have changed over time and in many cases reflect the programmer’s best guess.

Absence of Context for Confounding Factors

Rationale (e.g., programs may have been influenced to a considerable degree by a particular institution’s financial situation or footprint limitations) for the programmed spaces was not explicitly stated in many of the programs, especially those completed before the mid-1980s. Consequently, the rationale was inferred or collected informally from colleagues and project staff; however, there was no standardized investigation into these factors.

Primary Driving Forces of the Super-Sizing Phenomenon

Historical growth in programmed space may be attributed to various factors depending on the year of construction, regional variability, or even the level of urbanization in a particular community. Some of the strongest contributors to the observed super-sizing phenomenon within the programming recommendations of this healthcare consulting firm (and perhaps within the broader field) can be attributed to the following:
• changes occurring in both operational and patient care models;
• greater consumer demand and increasing market competition;
• increases in average patient acuity and disease prevalence
• the dramatic evolution and impact of technology, and
• the modification of regulations and building codes

Patient Care and Operational Models

Patient care standards, technology and operational models have evolved over the past 30 years, requiring additional space for the delivery of care and support in direct proximity to hospital inpatients. The adoption of a multidisciplinary team approach, especially at academic and teaching institutions, and the distribution of care team support closer to the bedside have created an increased demand for consultation/conferencing rooms and computer documentation stations. Ancillary staff (e.g., social workers, utilization/case managers and dieticians) in particular, have an increasing role in the care team and spend substantial time either dedicated to particular units or floating between units—a trend unlikely to reverse anytime soon. The convergence of surgery and imaging technologies also has driven the desire for larger floor-plates as practitioners seek horizontal adjacency among various modalities. The shift toward more ambulatory or short-stay procedures has propelled growth in the size and quantity of periprocedural (prep and recovery) care stations. Perhaps most significantly, the transition from shared to single-bed patient rooms has increased the space requirement to accommodate the same number of beds for clinical and nonclinical amenities alike (e.g., rooming-in space for families, private patient toilets/showers, monitoring equipment, workspace for caregivers).

Consumerism and Market Competition

Consumer-driven health care has elevated patient expectations relative to levels of service, amenities and ambiance. Fueled by consumer demand, hospitals have had to become increasingly competitive, seeking to differentiate themselves from their competition based on service and thereby capture an increased share of the market. Some of the byproducts of this competition include increased patient room size and the provision of an extensive array of in-house services (e.g., business centers, family lounges with full-size kitchens). With respect to patient rooms, not only has the trend accelerated toward providing single-bed rooms for their health and safety benefits, but private toilets and showers have become standard, as well as additional space to accommodate specific populations (e.g., bariatric patients). More spacious rooms also permit the introduction and gradual adoption of care models that encourage family participation in the care of patients, including rooming-in and other requirements that have affected the layout and size of inpatient units.

… [T]he transition from shared to single-bed patient rooms has increased the space requirement to accommodate the same number of beds for clinical and nonclinical amenities alike …

Furthermore, consumerism is not limited only to patients. The recruitment of renowned clinicians has become a competition, where the promise of large, state-of-the-art facilities (e.g., large operating room suites, clinic space, faculty offices) is used to attract a coveted recruit.

Patient Acuity and Disease Prevalence

Many patients who historically were treated within the hospital are now seen in ambulatory environments. Traditionally these patients were those with lower relative acuity; therefore, the overall health of the population seen within the hospital has decreased. Higher-acuity patients require more support, additional technology and higher levels of staffing. In addition, the advancing age demographic in the United States has led to a demand for more capacity (beds, procedural areas, technology) within the acute care environment. Changing rates of incidence and prevalence of disease have also contributed to the need for different types of space (e.g., more, larger and different diagnostic and treatment areas; bariatric-sized rooms).


Infrastructure requirements for both MEP systems and IT have significantly increased, requiring greater floor-to-floor heights, interstitial spaces and spaces to accommodate increasingly sophisticated heating, ventilating and air conditioning (HVAC); communications; and transport systems, thus affecting total building size. The availability and proliferation of clinical technologies (e.g., MRI, interventional radiology, surgery robotics and lasers) has changed the standard of care and played a role in the supersizing of diagnostic and treatment departments. The number of biomedical devices has similarly increased, supporting the cause for larger patient rooms. Patient-centered care models have also had a tangible effect on moving procedures and equipment to the bedside, including monitors, automated pumps and portable imaging equipment. As the range of equipment and number of portable devices increase, space is needed for storage and maintenance (i.e., the amount of storage per operating room). The use of robotics and automation for logistics and clinical support functions has proven to be space intensive. The use of automated lab systems, pharmacy robots and robotic distribution systems that require their own internal transport routes have all contributed to the super-sized environment.

The movement toward point-of-care IT has required additional space within patient rooms, in corridors, and at nursing and clinician workstations. Similar increases have occurred in administrative areas. Supporting this increased use of technology has led to a growth in technology support spaces for network infrastructure, cabling and data center spaces, as well as increased capacity requirements for HVAC and electrical infrastructures. The fuller adoption of point-of-care technologies reduces the space needed for record storage (e.g., medical charts, radiology films) space; however, the net effect is the need for more space.

Regulations and Building Codes

International, national, state and local regulations have mandated minimum requirements for many functions within hospitals. For example, the American Institute of Architects’ (AIA) guidelines have changed significantly in the last 30 years and now recommend private patient-centered care rooms at 250 NSF plus 30 NSF for each additional person (i.e., family member) (AIA, 2006). Similarly, the Americans with Disabilities Act (ADA) requires a percentage of wheelchair-accessible rooms and toilets (ADA, 2008). Building codes also have evolved, an example being the introduction of USP 797 regulations for preparation of sterile intravenous solutions in clean rooms in inpatient pharmacies (U.S. Pharmacopeia, 2008). Corridors have become wider, fire safety and seismic requirements have increased and public health requirements (e.g., more quarantine/isolation rooms to accommodate mass casualties) are of greater concern. Each of these changes has contributed to the requirement for additional space.

Looking Back: Is the Growth Justified?

This large consulting firm, with an international practice that includes the programming of health care capital projects, views growth as justified when it is warranted or seems likely to improve a space’s capabilities or functionality, whereas unjustified growth does not contribute directly to functionality or adds an element of flexibility that is not likely to be used. Excessive elements are those exceeding a customary limit or demonstrating an unnecessary amount of what is being measured (e.g., square feet, money, time, resources). An element may be considered excessive (i.e., larger than anticipated) while still being justified (e.g., improves functionality). That said, correct sizing depends on the operational model of the department; the aggregate size of the medical center; the degree of teaching, research, or other nonclinical uses anticipated; the level of automation; internal political agreements; local regulations; and numerous other variables. For example, on-site materials stores must meet regulations for emergency storage at a minimum, but the threshold into excessive on-site storage varies drastically across comparable campuses and may be more a matter of interpretation.

Total building size is highly variable and, as a result, BGSF per inpatient bed is not a valid comparator at the macro level. Traditionally this value has ranged from 1,500–2,500 BGSF per inpatient bed; however, the value can range considerably higher and is contingent on the functions included within the building (i.e., degree of ambulatory services, support/logistics, research and education) as well as circulation patterns and the level and sophistication of MEP and technology infrastructure within the building.

Guessing at an unknown future, programmers often err on the side of too much flexibility.

Unjustified: Excessive Room Sizes

Although private patient rooms are most often justified for reasons of operational efficiency, patient safety and comfort, rooms larger than 320 NSF may be deemed excessive (includes handicap-accessible toilet and shower, caregiver work space, family space). Similarly, major operating rooms larger than 750 NSF may not improve the room’s functionality but instead use excess floor area for equipment storage. Imaging room sizes have been directly influenced by equipment size, but “big box rooms” (i.e., MRI, CT, PET) of more than 860 net square feet (includes procedure room of 560 NSF [28' x 20'] and 250 NSF control/computer room) may be considered excessive. It is notable that the functionality of the square footage is highly dependent on layout and configuration.

Unjustified: Greatest Common-Denominator Planning (Excessive Standardization)

In the quest to make space as flexible as possible for the future (based on lessons of the past), programmers are increasingly sizing to the greatest common denominator. Guessing at an unknown future, programmers often err on the side of too much flexibility. For example, it is not uncommon to use a standard big box room size for major imaging modalities, even though CT requires less space than MRI or PET. This anticipation of future modality shifts and “fusion technologies” not yet on the horizon may provide a questionable return on investment. Although standardization has been the golden rule for many years, planners must acknowledge the premium for excessive or unnecessary flexibility.

Unjustified: Underutilization of Space

Highly specialized rooms, spaces poorly located or otherwise planned with the wrong department, dedicated spaces for functions that will become obsolete and dedicated spaces that could be shared across multiple departments are red flags for potentially super-sized departments. Similarly, excessive shelled or non-built-out spaces (i.e., not functional without additional construction) included to enhance future flexibility (if financially feasible) may be allocated at some future date to non-revenue-generating functions, which can unnecessarily oversize buildings. In general, poor design or an inefficient configuration is that which necessitates greater levels of staffing or increased fixed cost per unit (e.g., fewer beds per acute care unit, multiple entries and underutilization of space, such as large lobbies with no programmed purpose).

Unjustified: Inefficient Operations

Often spaces are planned to accommodate duplication of services or staff, non-value-added spaces and poor patient or materials flow. Personal preferences for desirable hours of operation may adversely impact the efficiency of an area (e.g., physician preference for early slots on the operating room schedule may drive a preference for more operating rooms). Planning and building too many rooms (too much capacity) or the wrong rooms for future needs result directly in size creep.

Unjustified: Excessive Capacity Based on the Scale of a Department

The scale of a department should determine its capacity. Unnecessary features may include, for example, multiple private conference rooms, too many waiting chairs per exam room, private offices for nonsupervisory staff or too many single-function information desks. Often these spaces go unused or unstaffed and create way-finding and flow problems in addition to increasing project size and cost.

Unjustified: Excessive Grossing Factors

Excessive NSF to DGSF grossing factors may allow for architectural flexibility of a department’s configuration, but it can result in travel distances for staff or patients that are too great and that increase building size without a commensurate increase in throughput.

Unjustified: Location of Nonessential Services Within the Inpatient Setting

Essential services are those that must be located within an inpatient medical center. Many organizations employ the tactic of moving nonessential services or functions not directly involved in direct patient care to adjacent, nonhospital buildings. These buildings may be built to less than an inpatient code and are therefore somewhat smaller and include functions that need not be inside a hospital (e.g., ambulatory clinics, faculty offices, non-unit-based administrative offices, logistics support [laundry, materials warehousing, workshops], large group education rooms and basic research facilities). However, there is often a need for “stub,” or duplicate, space in the main hospital building to handle the interface with these off-site services (e.g., laundry staging area, physician workrooms). Telephony, computerization and multimedia communications have also enhanced the ability to move back-office functions out of the main hospital building.

Unjustified: Unrealistic Volume Basis

Building capacity may be planned to meet unrealistic projected volumes of care. For example, if a hospital will be open in 2009, it may be considered excessive to build for volumes projected for 2025 (as opposed to developing a master plan that accommodates future expansion to this capacity and deferring the capital investment).

Looking Forward: Future Trends

The future direction of the health care industry is a matter of some debate. Within broad boundaries, however, and tied to specific political cycles, one may speculate about several phases in our immediate future when forces will be set in motion that will exert pressure to slow the increase in project size or begin to reduce size in absolute terms.

National War Over Resources: 2008–2012

In this timeframe, the major sources of health care revenue (taxes, premiums, deductibles) are not expected to keep pace with spending, leading to an extended period of belt-tightening. As a result, health care systems will begin to face anti-super-sizing pushbacks that will discourage excess, such as:

  • Restricted capital availability (due to increased cost of debt, poor ratings, excessive leverage or other factors) will increase scrutiny and require more extensive justification of space requirements. A growing imperative for cost/benefit and return-on-investment analysis will be seen because additional space and capital investments will need to offset future operating costs and improve clinical outcomes.
  • Competing needs and priorities will require more robust business cases for new medical center construction. Without these, capital will be siphoned toward technology solutions, research, education or ambulatory construction. In all cases, strategic priorities (i.e., those related to incremental growth) will be viewed more favorably than those related to replacement (i.e., increased capital for no incremental revenue) without significant external justification (e.g., seismic requirements or other risk-related justifications).
  • Rapidly rising construction costs will focus development on incremental capacity, deferring replacement of non-revenue-generating services and extending the life of existing facilities.
  • Rising operational costs, primarily caused by workforce availability and other resource shortages (e.g., energy), will begin to push down building size as inefficient operations become intolerable.
  • Site and zoning restrictions and neighborhood alliances will begin to play a more active role in restricting the health care built environment, based on increased activism regarding neighborhood rights and the ability to contest rezoning.
  • National health care policy will continue to affect reimbursement and incentives for construction of facilities to accommodate more profitable services. Payers’ cost awareness will be heightened, and they will resist blatant excesses.

In addition to these anti-super-sizing pushbacks, future clinical trends likewise will play an important role in defining the degree of facility growth. Whether it be the next wave of medicine (e.g., genomics, molecular imaging), home monitoring and diagnostic tools, telemedicine or other clinical advances, these trends will continue to expand the definitions of inpatient vs. outpatient care and will place increasing demands on IT infrastructure.

A final factor that will have an impact on facility size in this period is an increased focus on sustainability. Some attributes such as configuration requirements for natural light, building orientation and selection of mechanical systems may not fundamentally cause additional super-sizing, but the trend may affect the length of useful building life and favor anti-super-sizing forces (i.e., operational costs).

Resolution and Legislation: 2012–2020

While the health care industry experiences increasing economic pressure leading to legislation, society will begin to question expensive facilities. The clinical enterprise will be under increasing pressure from consumers and payers to demonstrate the value it provides in facility excesses (e.g., extreme size, expensive finishes). By means of increased consumer advocacy, patients will develop a better understanding of health care costs; payers will develop more sophisticated processes to measure quality, cost, and the overall value of health care services. Medical centers will be forced to validate, through clinical and outcomes research, that new facilities enhance patient safety, comfort and length of stay as well as staff satisfaction, recruitment, retention and productivity. Demonstrating a positive effect on an institution’s viability—particularly its financial health and community image—will be increasingly valued.

Consequently, organizations will no longer be able to plan for all eventualities or the greatest common denominator; they will have to specify how capital and space are deployed.

While the marginal benefit of including unjustified or excess space in a project currently may outweigh operational and related construction costs, super-sized facilities will begin to experience decreasing (and eventually negative) marginal benefit in the future. In short, sizing facilities in excess of what may be considered functional or reasonable, especially in terms of committed capital and staff resources, will produce undesirable effects fiscally, socially and politically for the sponsoring organization.

Balancing these pushbacks, the majority of the Baby Boomer generation (born 1946–1964) will be crossing into retirement (and Medicare) in this period. This will drive two eventualities. First, there will be a huge increase in inpatient demand, which means hospitals will want to keep open every bed possible (even in inefficient facilities). Second, this is the most politically active age cohort in the history of the country, and there will be an expectation that they be treated (free of cost, because they will have paid into Medicare all their adult lives) in roomy, state-of-the-art facilities.

Obsolescence Catches Up: 2020–2025

Building life spans in health care are roughly 50–70 years, and within 20 years we will reach a point where hospitals built before 1980 will be considered nonfunctional in many parts of the United States. Significant demographic shifts (e.g., northeast to southwest), deferred investment

Countervailing forces such as limited capital availability and the continued escalation of construction costs will likely accelerate the downward pressure on sizing excess.

in health facility infrastructure and operational cost pressures will lead to a point of crisis for society when the cost of new acute health care capacity and upgrading old capacity will outrun the resources of a largely not-for-profit industry.


During the last 30 years, hospital rooms, departments and overall buildings that the health consulting firm has programmed for the health care industry have grown in size, as evidenced by this analysis. In some cases these spaces have been excessive or super-sized; however, the existence of unjustified space in facilities programmed by other firms suggests that the firm under consideration is not alone. The verdict on the benefits versus costs of additional programmed space is anything but clear-cut, and opinions vary by user and institution. This observed creep in size is the result of multiple contributing factors that have varied by time and place; they include changing patient care models, consumerism and technology trends. Although it is likely that these trends will continue in the short term, the consulting firm examined believes that increased size will require increased justification. Eventually the industry will reach a “super-sizing plateau,” the point at which growth per unit of capacity slows and then ceases. Countervailing forces such as limited capital availability and the continued escalation of construction costs will likely accelerate the downward pressure on sizing excess. Inevitably, the basic “bigger is better” mentality will fundamentally shift to one of “more is just more.”

As space programmers, we hold out hope for resolution, noting that other industries have managed to improve processes and quality, reduce cost and quantify outcomes. We must take the quantum leap to do the same. Instead of looking back in regret over failed building plans or forward in fear, believing that we must program and build to the worst-case scenario, we must focus on the present—opting to build that which is operationally efficient, financially feasible and clinically appropriate.


ADA (2008). The Americans with Disabilities Act of 1990 is federal legislation requiring that buildings be made accessible to persons with physical and certain defined mental disabilities. Retrieved March 1, 2008, from http://www.usdoj.gov/crt/ada/.

American Institute of Architects (2006). Guidelines for design and construction of health care facilities (2006 ed.). Washington, DC: AIA.

Carpenter, D. (2008, February). Hospital building report: No end in sight. Health Facilities Management, 21(2), 15–22.

Kurt Salmon Space Programming Database (1980–2008). Data include programmed inpatient medical centers, which do not reflect actual construction.

U.S. Pharmacopeia. (2008). Pharmaceutical Compounding—Sterile Preparations. Chapter 797. Retrieved March 1, 2008, from http://www.usp.org/USPNF/pf/generalChapter797.html.

1 June 2008