If all goes according to plan, sometime next year, 30 million more Americans will have access to health insurance to pay for regular checkups and preventive care. The prospect of this greatly expanded customer base, along with a focus on wellness and incentives to deliver care more efficiently, has U.S. hospitals and health systems looking at how and where they treat patients who will be more actively engaged in their own health and well-being.  Going to where the customer is—out in the community—is a primary strategy that has hospitals and health systems around the country busily forming networks of ambulatory care centers, physician practices, and urgent care centers. To attract patients who will have a number of choices for where they receive their healthcare, providers are also upgrading facilities to support a new model of delivery that will rely heavily on technology and teamwork.

 “The biggest challenge is that we’re creating this more distributed model of healthcare with ambulatory facilities in today’s healthcare world, knowing that world is going to be very different five to seven years from now,” says Kip Edwards, vice president, development and construction for Banner Health (Phoenix), which is opening new clinics at a rate of four to six per year across seven different states. “We’re putting these facilities out there and configuring them for the future, but they also have to work for today.”

Come together
Designing flexible spaces that accommodate new technology and care teams means fewer walls and more shared spaces—a trend that started in corporate offices more than a decade ago. Wireless technologies enable doctors and nurses to work with patients in various settings, communicating through email, videoconferencing, streaming media, and remote monitoring and robotics. Edwards believes that in the future, most routine office visits will be e-visits. “Today, we’re building exam rooms, but tomorrow we’ll need more group spaces,” he says.

And, if patients do come into the clinic, they’ll most likely check in and register electronically, eliminating the need for spaces to support those activities. But Edwards acknowledges that not all patients will be receptive to less person-to-person contact. “As we think of our facilities, we have to design for any and every way that people want to interact with us,” he says.

For the Mayo Clinic in Rochester, Minn., the ambulatory care center of the future may not even be a clinic facility. “We learned that for most clinic visits, patients weren’t coming to see the doctor or nurse practitioner,” says Douglas L. Wood, medical director for Mayo’s Center for Innovation. “They were coming for physical therapy, to visit with a dietician or counselor, or to get an immunization—things that could be done from home, in the grocery store, at school, at work, or at a health club. We’re still looking at how we can deliver care outside of the traditional clinic.”

In the ambulatory care centers it does have and is contemplating building, Mayo is looking at developing more common spaces, including those that can be used for community activities to promote health and wellness. “We haven’t built it yet, but are definitely considering the possibility,” says Wood.

Common spaces are also needed to accommodate the growing trend of shared medical appointments, or group visits, which have been shown to be effective in disease management for conditions such as diabetes.



Hoteling comes to healthcare
For doctors and nurses working in ambulatory care centers, the physical workplace is changing. “Instead of a rigid hierarchy, we’re creating more common spaces and smaller, flexible private spaces,” says Steve Johnson, senior vice president, Gresham, Smith and Partners (GS&P; Nashville, Tenn.), adding that the concept of “hoteling”—a method of supporting unassigned seating in workplaces—started in the corporate world a while back.

Physicians are also using spaces differently. “There are no big, private offices with wood furniture anymore,” Johnson says. “The doctor comes in, touches down, goes to a hub/workstation, and interacts with staff.”

Because care is increasingly being delivered by multidisciplinary teams, spaces that facilitate teamwork are essential. Rooms that accommodate interaction—face-to-face as well as via technology channels—are much different than traditional exam rooms, using a table and chairs that allow people to sit facing one another or looking at a screen, if necessary. Wood and his colleagues at Mayo believe that the greatest benefit to the patient is collaboration within the care team, which makes it critical to create services and spaces that focus on building relationships. “An important part of teamwork is for people to be collocated and cross paths during the day,” he says. “The office space becomes an important facilitator.”

Building in future flexibility for changing methods of care delivery means more modularity, too, including more use of demountable partitions, fewer built-ins, prefabrication of components, and modular furniture.  “Standardization within a clinic type has been around a while,” said Roger Swanson, vice president, Stantec Architecture (San Francisco), emphasizing that flexibility starts with the design of the structural and mechanical systems.

For a new clinic building at Valley Health Center Milpitas in Milpitas, Calif., Stantec built in flexibility by designing a 10-by-12-square-foot module for exam rooms and offices. A toilet room is half this size, and a procedure room is 1.5 times larger, thereby enabling increasing or subdividing in the future, as needed. Plumbing was also roughed out into a number of offices so they could be changed to exam rooms. Medical records and pharmacy areas were left open with no internal dividing walls and plenty of power on perimeter walls to enable future adjustments or conversion to other functions. The firm applied a similar “kit of parts” for two other clinics it designed for the Santa Clara Valley Health and Hospital System in California.

Renovate or build new?
According to Healthcare Design’s 2013 Corporate Rankings survey, architecture/engineering and construction firms indicated that ambulatory projects were gaining ground in 2012, with 86 percent of respondents engaged in both ambulatory surgery center and medical office building projects, 74 percent in standalone clinic projects, 53 percent in ambulatory “other,” and 18 percent in retail-based
clinics. Meanwhile, overall business continued to skew very slightly toward new construction with 53 percent of projects new builds, but renovations are quickly catching up, growing from 43 percent of business in 2011 to 47 percent in 2012. This data supports the trend toward expanding ambulatory care and suggests that more providers will be considering renovating or retrofitting existing facilities instead of building new.

Across the country, recent economic downturns have shuttered many big retail and office buildings. In Silicon Valley, for example, near Stantec’s San Francisco office, Swanson says that the dot-com bust produced a lot of empty buildings that are being retrofitted into clinics. “We may run out of retrofittable buildings,” he cautions. “Over the next 10 years, we’re going to see a lot of [hospital] facility assets allocated to different kinds of spaces.

Paul Pannier, senior architect with GS&P (Ft. Lauderdale, Fla.), says that retrofitting a retail building is less expensive than building a new clinic. Plus, the locations of retail properties make them ideal for clinics and can help revitalize communities. “We’re seeing a lot of renovation,” he says, pointing to 100 Oaks Mall in Nashville as an example. Before Vanderbilt Medical Center took over the property, it was a rundown, dying shopping mall. Working with GS&P, Vanderbilt converted it into a successful, mixed-use medical office and ambulatory care site.

The migration of seniors back to more urban settings is also a factor to consider when locating a clinic and deciding between building new and retrofitting. In a 2010 survey by AARP, almost one-half of adults age 45 or older said that living in a place that’s near where they want to go—church, grocery store, doctor’s office, etc.—was important.

According to Banner Health’s Edwards, the large, open floor plates of grocery stores make them ideal clinic buildings. “We just bought a grocery store that we’re going to turn into a health center,” he says, adding that 6,000 square feet is the optimal size. GS&P’s Pannier thinks that the most important issues for outpatient centers are the same for retail:  location and ease of access, including parking. “Existing spaces generally also have fixed points of entry for the public and for service doors, so the design in these spaces tends to have fewer options for circulation points in the plans,” he says. “Ceiling heights in strip centers and box stores are generally higher than in older concrete buildings, so there is more flexibility in the overall layout of building systems in these newer retail centers.”

Since the shell costs for perimeter walls and the roof are already in place, retrofit costs are typically less than new facilities, too. However, says Pannier, “Common costs overlooked by the developer are emergency power services, medical gas services, and the backup power required for life-safety systems in a licensed outpatient center. Many retail spaces do not have these services on site, and upgrading a property can increase the overall project cost beyond fit out of a building that already has these utilities.” (For more on converting old retail building into healthcare space, see "Creating A Sustainable Healthcare Space By Recycling A Big-Box Store").

Building design and branding
As healthcare providers expand their reach into communities, building design can serve as an important branding element. “Architecture will have a greater impact on branding,” says Bruce Crockford, senior vice president, regional healthcare lead for Jones Lange LaSalle. “Like McDonalds and Starbucks, the image of the facility brands the service.”

The building design can offer clues to what that experience is going to be before patients even get in the door. “Healthcare organizations have to think more like retailers or hospitality [companies] to develop a patient experience that’s meaningful and satisfying,” says GSP’s Johnson. Johnson says the Panera Bread model is being adopted by some of his clients, which are creating a series of comfortable living-room-type spaces within the environment.

Architectural components of branding include consistency in style, language of materials, detailing, and elements. For clinics in the Santa Clara Valley Health and Hospital System, Stantec is designing rotunda lobbies and creating a more modern, sleek look that reflects an economic region that is home to so many technology companies. The materiality and exterior building concept of the newest clinic in Milpitas, Calif., also builds on language Stantec established at the organization’s other health centers, while allowing the new building to express its own particular idiosyncrasies informed by site geography, geology, and particularities of climate and orientation. The durable exterior material palette includes architectural pre-cast concrete panels, aluminum curtain wall, aluminum panel cladding, and curved metal panel canopies with metal awning shade control systems to address solar loads.

According to Swanson, the clinic buildings for Santa Clara Valley Health need to look like they belong in their own neighborhoods, but “People should be able to see the consistencies and differences, and yet have the feeling they are in the same place,” Fast food companies, like Starbucks, Panera, and McDonalds, have been using building design as branding for many years. Customers experience a certain look and feel, no matter which store they visit or in which part of the country. Healthcare systems are trying to do the same thing with their ambulatory care facilities.  

Ana Pinto-Alexander, senior vice president and director of healthcare architecture at HKS Inc. (Dallas), says that the interior materials and finishes can also tell the story of the organization and its culture. “You have to be able to connect emotions with the materials,” she stated, explaining that warmer finishes, such as wood, can provide a more experiential impression.

At the other end of the spectrum are the retail-based clinics in pharmacies and big box retailers. The Convenient Care Association reports that the number of health clinics inside retail chain stores has doubled from six years ago to 1,400. Walgreens and CVS have partnered with health systems to offer clinic-based care and Wal-Mart is leasing space to local healthcare providers. Branding and design could become increasingly important as consumers have more options of where to get their care (See "Burgeoning Retail Clinics Require Unique Designs" for more on this segment of the ambulatory market).

Outpatient experience
For Stantec’s Swanson, the goal is to make clinic spaces as effective and efficient as possible without giving people the “cattle car experience.” And there are some design elements that always need attention, whether it’s inpatient or outpatient care. First, there’s wayfinding:  &
ldquo;Integrating a navigation system that’s cohesive and consistent throughout the building, from arrival to the desired destination, can support the story and culture that the [clinic] wants to reflect,” says HKS’s Pinto-Alexander. In addition, she says that managing all cues—from how the caregivers provide care to their attire and body language to the cleanliness, smells, and appearance of all the facilities within a network—ties the branding together.

Huelat maintains that healthcare consumers are not looking for marble and fancy finishes, but they do want comfort. “They don’t want to be squeezed into small waiting rooms and exam rooms,” she says. “They need places for family, children, and elderly parents.” Many ambulatory care projects Huelat is working on include spaces for child care and coffee/fruit bars, along with positive distractions, such as a puzzle table and television programming with educational health segments.

“Outpatient care is all about ease of arrival and access,” says Banner’s Edwards. Once you get inside, you want quick movement into your appointment. Healthcare has always needed to create pleasant surroundings. It’s still important.”

The future
According to Edwards, the new wellness-based model of care that’s driving the shift to ambulatory settings works financially, citing both Intermountain Health and Kaiser Permanente as examples of systems that are already making the shift to a value-based care model that’s focused on patient outcomes rather than volume. He believes, though, that it will take 7-10 years for a complete shift to the new model and that healthcare consumers are the ones who may be reluctant to change. The success of the new system depends on healthcare consumers wanting to take better care of themselves and managing chronic diseases, rather than waiting until they get ill before seeking treatment. “People in the healthcare industry get it, but the general public is where it could unravel,” Edwards says.

The most important thing that architects and designers can do in this new but uncertain world of ambulatory care is to continue to come up with innovative ways to build in flexibility. “It’s not okay for architects to be order-takers anymore,” says Jones Lange LaSalle’s Crockford. “They need to provide input into the process and challenge conventional thinking.”

Edwards agrees, with one caveat: “We don’t need monuments to architecture. We need good, community-based healthcare facilities that are easy to access, pleasant for patients and staff, and flexible for the future.”


Sara O. Marberry, EDAC, is a contributing editor for Healthcare Design. She is a writer, blogger, speaker, and strategic marketing and business consultant in Evanston, Ill., and the former executive vice president of The Center for Health Design. She can be reached at sara@saramarberry.com.


Sidebar: What healthcare consumers want from ambulatory care
Barbara Huelat, principal, Huelat Parimucha: Healing Design, shares these tricks of the trade in planning and designing ambulatory settings.

  • Location: Easy to find, close, easy to park.
  • Respect of time: Get in and out, with minimal waiting.
  • One-stop shopping: Blood work, labs, X-rays, diagnostics, and office visits—all in one place.
  • Privacy and dignity: Private consultation and check-in.
  • Comfortable: Plenty of space for family, children