All Together Now: POE Insights Into Clinic Design
The operations of many new outpatient clinics are designed to support the Patient-Centered Medical Home (PCMH) model, a concept that was codified by four major physician associations in the “Joint Principles of the Patient-Centered Medical Home” white paper in 2007. Principles include care coordination, physician-directed teams, and whole-person orientation, among others. In addition, many clinic planners have adopted some form of Lean planning to improve various patient care outcomes and create staff efficiencies through eliminating wasteful steps from their operation.
Traditional clinic planning typologies pose challenges to meeting these goals, because they often separate care teams (physician offices in separate locations from medical assistant stations), limiting team coordination and increasing walking distances (waste); also, these plans usually don’t support collaboration with care coordinators and ancillary care professionals like nutritionists and behaviorists. In order to support PCMH and Lean goals, at least two successful typologies are emerging—open team centers and on-stage/off-stage approaches, both of which colocate more comprehensive care teams to optimize coordination, collaboration, and efficiency.
Healthcare design firm Clark/Kjos Architects (Portland, Ore.) performed post-occupancy evaluations of four clinics designed by the firm using the open team center model, each with a different approach, to learn what specific design strategies are most successful in meeting the PCMH and Lean goals. They are all similar in size, with 18 to 21 exam rooms. Clinic staff completed online surveys with their judgments related to both care team communications and efficiency factors related to walking distance. The four clinics evaluated are:
- Clinic A: Open team center with provider stations partially enclosed with patterned glass
- Clinic B: Open team center with provider stations partially enclosed with solid walls
- Clinic C: Racetrack plan with provider stations partially enclosed with solid walls
- Clinic D: Open team center with provider stations enclosed with glass, frosted at sitting height.
The post-occupancy surveys yielded some clear lessons for designers who are working with the open team center model.
Patient rooming: patient (patient travel from clinic entrance to exam room). The distance from the clinic entrance to the exam room ranged from 170 to 243 feet (median for each clinic). The surprising difference between the clinics studied is the added walking distance created by some waiting room sizes and shapes. As a result, the designers recommend placing the waiting room as close as possible to the exam room cluster, as well as minimizing the distances within the waiting room, which is especially important for those with disabilities.
Patient rooming: staff (staff travel from their workstation to escort patients from waiting to exam). The distance from the medical assistant’s station to the clinic entrance, then to the exam room (median for each clinic), ranged from 83 to 276 feet. As found with patients, this is partly a factor of distance between the waiting room and the exam room cluster. But for medical assistants (MAs) rooming a patient, the workstation-to-waiting-room distance also exacerbates the distance traveled. It’s worth noting that for on-stage/off-stage concepts (not a part of this study), patient rooming is by patients alone in a separate corridor, so the medical assistant doesn’t have this travel distance, which would likely create higher overall efficiency for staff.
MA walking during patient’s stay in exam room, measured directly from workstation to exam room (median distance for all staff stations and exam rooms). Clinics A, B, and D have significantly shorter travel distances (19 to 21 feet) than the racetrack approach in Clinic C (36 feet); this is due to the many solid elements in the center of the exam room cluster.
Visual control (situational awareness by staff of location of patients and other staff)
MAs: How a staff member is oriented within the team center is important. Surveys as well as anecdotal comments indicated that having all workstations directly facing exam rooms is highly preferable (visibility to exam room doors with line of sight when seated). This is clearly correlated by the surveys. Clinic A scored highest (MAs face nearly all exam rooms), and Clinic D scored lowest (MAs face only about 75 percent of exam rooms).
Providers: Surveys indicated that providers also favor visibility of corridors; Clinic A scored highest (patterned glass enclosure allows filtered view of corridors when seated) and Clinic B scored lowest (solid wall disallows view of corridors when seated).
MAs: Survey scores are very high for all four of the open team center clinics for “facilitating communication with providers and other staff,” indicating that both open and walled workstations support this factor when adjacent to one another. Comments indicated a preference for proximity to providers as well as a private space to huddle with providers.
Providers: All four clinics surveyed have shared workstations for two to three providers. All providers responded with high favorability. Comments in the survey indicate that providers prefer close access to MAs, as well.
Work privacy and confidentiality
MAs: Comments indicate a need for confidential consultation with providers, as open work areas with lower ceilings exacerbate sound, making concentration difficult for those working near conversation areas. Respondents in clinics A and D, which have high ceilings, didn’t report this problem, as these spaces have better sound dispersion. It’s important to consider raising ceilings where this option is available.
Providers: For this factor, Clinic A scored very high, having patterned glass at provider workstations, which allows some filtered views into provider space from the corridor. Clinic D scored very high (it has enclosed, glass-walled rooms). Comments from some providers indicate that open workstations, all with at least 6-foot-high enclosures, lack acoustical privacy for telephone and dictation use.
Four additional clinics are currently being surveyed to add to the body of evidence in the firm’s ongoing study, to be reported later. As more research into effective design strategies emerges, designers will be able to create the most supportive solutions for collaborative care teams. Other influential issues need to be studied, such as the additional space (and related costs) required for the on-stage/off-stage approaches, ceiling height effects, various types of workstation enclosures, alternative plans, and others. Stay tuned.
Tom Clark, FAIA, EDAC, is a principal for planning and design for Clark/Kjos Architects (Portland, Ore.). He is president-elect of the American Institute of Architects’ Academy of Architecture for Health. He can be reached at email@example.com.