In 2015, UNC Health Care based in Chapel Hill, N.C., began an intentional transition from volume-based to value-based care delivery, said Cameron Ebron, senior planning manager for real estate and development at UNC Health Care, University of North Carolina Health Care System, during the session “Contemplating Clinic Configurations for Continuous Improvement,” at HCD Virtual, Nov. 9-12.

Part of that process included redesigning its ambulatory care offering, both in terms of the care delivery as well as the physical environment itself to support care coordination and flexibility. To accomplish this, Ebron said, “We realized our system needed to stop looking back at what we had been doing and start looking forward.”

Along with panelists Esperanza Harper, healthcare planner at LS3P, and Ron Smith, healthcare architect and senior associate at LS3P, the speakers talked about that process, using a project at UNC Family Medicine and Pediatrics at Panther Creek in Cary, N.C.

In 2018, the project team was finishing schematic design plans for a prototypical clinic model for one of the clinic’s floors when Smith said he had a sidebar conversation with one of the organization’s executives, ultimately proposing to step back and look at clinic design in a Lean design session with stakeholders to see how the operational flow might be improved and how architecture could support that, Smith said.

Leadership was receptive to the idea and a Lean operation workshop was conducted on the existing layout and then another to explore onstage/offstage operations. In the end, the project team decided to go with an onstage/offstage model and to use the clinic design for the family medicine practice as a pilot project to test its effectiveness.

“This was a big plan for us and a leap of faith,” Cameron says. The group hypothesized that one of the benefits of the new layout would be improved team communications as compared with a traditional layout, Ebron said. “We had some specific and exciting goals we were looking to accomplish,” she said.

For example, the team wanted to use separate traffic patterns for patients and staff to improve patient and staff satisfaction; utilize collaborative providers and open sightlines to improve communication; and standardization in room layout to decrease waste in time resource utilization. “That began our journey,” she said, with the clinic opening in January 2020.

However, Harper said designers also recognized that many clients have an affinity for the traditional and racetrack configurations so the firm dove into a study comparing the spatial analysis of three trending outpatient clinic configurations: the traditional pod configuration, the onstage/offstage model, and the racetrack configuration.

The study found three comparable clinics within UNC’s network and developed a three-pronged study that incorporated spatial syntax analysis to gather quantitative data, staff and patient surveys to gather qualitative data, and behavioral observations. “Through this multimethod approach, we sought to deeper our understanding of clinic configurations,” she said.

For the space syntax analysis, which measures the effects of architecture on how users move within a space, the study sought input on three measures: connectively, or a person’s direct connection to other spaces; step depth, or how many space a person has to go through to get from one space to another; and integration and visual integration, which measures distance from origin to all other areas. A depth map was used to evaluate the three variables in each of the three clinic layouts.

Among the findings, connectivity was high in circulation zones in the onstage/offstage and racetrack models, which can lead to easier navigation for patients. Looking at average integration by room type, nurses’ desks in the onstage/offstage layout had the highest value compared to the other two models, while in exam rooms, the traditional pod layout ranked highest. “Overall, the onstage/offstage configuration was the winner in the majority of the syntax categories,” Harper said.

Wrapping up, the speakers discussed some of the implications of the study on future design. For example, Harper said that corridors are not wasted space. “The corridors tend to be the place where people start to make a connection and exchange information,” she noted.

Another takeaway was that rightsizing is just as important in an outpatient setting, particularly when looking at the care-team setting, as it is in an inpatient environment. “Every activity is not conducive to highly integrated areas,” she said. Rather, facilities need to provide pockets for privacy without removing clinicians from other  staff members so exchanges can continue. “That balance is an opportunity to study further how to get that right,” she added.

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Anne DiNardo is executive editor of Healthcare Design. She can be reached at