The reality is that most people spend more waking hours at work than anywhere else. For those that work in the medical field, the majority of that time is spent in a medical facility such as a hospital, clinic, surgical center, urgent care clinic, specialty treatment facility, medical office, or diagnostic center. Even though so much time is spent in the work environment, how we feel about that space is usually subliminal and not something we consciously think of. Where you work is just a fact of life. Though some may grow frustrated working in an inefficient facility or confined to a space that is too small to “do the job right” — and they might even gripe from time to time — most eventually accept their work space and figure there isn’t much they can do about it. The truth is that the importance of this space, and its contribution to a business’s success or demise, is consistently underestimated.
The Importance of Your Physical Plant
The physical space you work in is an environment of its own, often neglected and misunderstood in its importance and impact on a practice or other healthcare facility. The physical plant can actually be considered a practice tool. Just like diagnostic and procedure equipment, how well it works is vitally important to the overall performance of the people that use it and the business as a whole. In a medical facility, this means physicians, employees, and patients.
First Steps First
When planning or evaluating a space, think first of the facility’s performance requirements before worrying about its ambience and how it looks, because an attractive building that is not big enough or that lacks the proper layout will cost you in lost revenue every single day. That’s right, no matter how attractive your facility or the décor is, it cannot overcome inefficiencies that cause disruption and waste time like a poorly laid out or insufficient space.
We rarely see a practice build a space that is too large. Decision-makers are far more likely to underestimate their space needs, often due to a focus on budget concerns that do not take into account or encourage growth. In these cases, not enough square footage is acquired, and the mistake is costly in the long run. Failing to recognize how important it is to identify your real space and function needs on the front end can result in a need to renovate or expand space long before it was intended, costing far more money than having done it right the first time. Additionally, the inefficiencies of an inadequate space drain a practice of resources every day. All of these contribute to an enormous loss in the long run.
It is important to take a diagnostic approach to examining how well existing space functions — what works well and what is hindering performance and patient service. Compromising performance and service are costly mistakes in the use of time and resources, as well as threatening your ability to be more patient-centered.
When considering how to apply your décor budget — which of course has an important influence on the patient experience as well as that of staff — you don’t want to skimp, but it is important to focus the majority of this budget on the reception area. This is a space that every patient encounters. Patients expect this space to be as comfortable and well put together as their own home, or more so. The clinical space décor is expected to be bright, clean, and simple.
It’s a Package Deal
Don’t overlook the obvious. Selecting a new space is not just a new suite, but often a new building. That means location, amenities, and parking convenience all need to be considered. In addition, what’s the area like? Can your patients easily transition to this new location? How is the signage leading to your suite? Are the neighboring businesses a good match for your practice? A pediatric practice next to a Hooters restaurant might not be a good idea. An orthodontist across from a middle school or a sports medicine practice near a fitness club sounds like a wise choice. When selecting new space think about the site itself, not just the space you will occupy.
Case Study: A Painful Mistake
Heidi Springer, MD, and Timothy Guard, MD, outgrew their rheumatology office space several years before they decided to make the big move and the even bigger investment in a new office. Finally, they were ready and spent the better part of a year looking for new space. The entire practice team remembered how quickly they outgrew the existing office, so they carefully thought about how much space they would need once they added another physician and another provider. They also wanted an infusion lounge to provide extra comfort for the patients. The doctors and their practice manager, Sandra Black, looked at many possibilities, and they ended up choosing an office with great visibility from the highway that was near a major intersection, giving them added exposure and making it easy for patients to find.
Once they decided on the office space they wanted, the design phase took another six months. They looked at drawing after drawing of floor plans, paying close attention to every detail. Sandra and the physicians addressed every shortcoming of their existing space and considered all the aspects of their future needs. The nursing supervisor was involved in the design of the clinical space and paid close attention to clinical flow and communication. Everyone was meticulous in analyzing their space needs and traffic flow, and privacy issues and OSHA requirements were evaluated. Once the floor plan was finalized, Sandra worked closely with the designer to make sure the interior was beautiful and the reception room would be both aesthetically pleasing and comfortable.
At long last, they moved in and were ready to see patients. The reception room was stunning, the administrative staff had plenty of room, the manager now had much needed privacy, and there was a conference room that also served as a staff lounge. The clinical area was spacious with a large nurses’ station, more treatment rooms, and a first-class infusion treatment lounge. They were prepared to grow. What they weren’t prepared for were their very own patients!
The practice consists mostly of adults, with more than 35% of those being senior citizens. The building they chose is three stories high. And though they are technically on the first floor, the first floor is actually a split-level. The new suite is on the upper half of the split-level. Patients are required to walk from the first floor parking lot, through the general lobby to a 10-step staircase or take a mechanical lift (not an elevator) to get to the suite. Not only is this inconvenient for older or handicapped patients, it’s confusing, as the suite is still considered part of the first floor. Patients taking the lift would push “2” thinking they needed to go up from what is obviously the first floor, but would end up on the floor above the suite because two levels were named “1.” No amount of signage or prior instruction to patients arriving at the office for the first time solved the problem. Patients arrive late, and senior citizens are quick to voice their displeasure. Many of them are afraid to take the lift, meaning they must take the stairs — handicapped or not. It is a painful mistake, and one that could have been avoided.
The practice selected an interior designer who had substantial experience with medical offices, but failed to hire a medical design architect. A medical architectural design firm certainly would have discouraged selecting a space that fails to meet the needs of a large portion of the practice’s existing patient population. It was a mistake this practice learned to regret and one that unfortunately can’t be reversed or repaired.
Function Following Form
When designing a medical facility, most practices and architects make the mistake of planning the design before they know how they need the space to function. There is more to the design of a medical facility than its physical plant. It is similar to industrial engineering, where you must organize all the functions of the plant to work together in order for the plant to function at its highest productivity.
Famous architect Louis Sullivan stated that “form follows function.” Consider the reverse in regard to medical facilities, “function follows form” — meaning a poorly functioning practice can be put in a very well-designed space, and its productivity will increase, and vice versa. Reaching the highest level of production requires well-organized and well-managed practice systems but also a well-designed physical space.
Maximize Profitability: Feeding Providers Efficiently
The reason renowned medical space planner and architect Larry Brooks named his firm “Practice Flow Solutions” instead of “Patient Flow Solutions” is because there is so much more that goes into the flow of a practice than patients. Patient flow is really the byproduct of all the other flow systems within the practice. This may be hard to grasp for those who work “in the trenches,” because in that case it’s often all about getting the patient through the system. In facility planning, however, there are many other considerations in addition to patient flow. For instance, if a practice has a well-designed space but schedules appointments at an impossible rate for the providers, the space (and practice) will seem chaotic, crowded, and inefficient.
In this situation, stress mounts at a rapid rate. What is interesting is that if you look only at the floor plan and fail to consider the specific function the practice requires of the space, it can look like an ideal plan with smooth patient flow.
To organize the systems and staff correctly, you have to know the projected potential patient volume of each provider. The general concept we use once we have the data on existing workflow is the funnel. The idea is to get all you can out of the doctors’ potential (small end of funnel — output), and all the systems and staffing upstream must have a little excess capacity (large end — queuing). This allows a steady stream of patients to the doctor. When providers’ time and skills are maximized and time is not wasted, practices become more efficient and profitable.
This small bit of excess capacity upstream (having just more than enough hands and staff time available than is ultimately needed) works for the appointment template, staffing, and space. You do not need a large amount, just a small amount more than the doctor needs or can handle. Regarding staffing, we like to see employees with a little time on their hands so they can make sure the doctor has all he or she needs and that the next patient is ready. If we go into a clinic and see staff running around busy, then we suspect the providers are, unknowingly, not using all their time wisely. This is because the staff is off doing something and not there to assist the doctors, so the doctors do things that should be delegated or lose time because patients are not ready when they are. Utilizing providers for lower level tasks is inefficient and costs a practice, hospital, or other healthcare system in lost revenue and compromised patient service.
This all ties in with knowing how much space you need and properly designing it, because the more efficient the practice is, the higher patient volume the practice will typically achieve. This means the practice will need more space and that space needs to be arranged to handle higher volumes of traffic. When done properly, the result is a thriving practice with a space that contributes to success and encourages growth.
Straightening Out Priorities
The most important consideration in designing a new medical facility is planning how it should function before you start drawing. This crucial step is one that will save you headaches and lost revenue because if you don’t get it right, you don’t get a chance to go back and do it over. We’ve seen plenty of practices stuck with a poor design once a build out is finished simply because they didn’t hire a professional to help them map out the functional requirements of the facility first. If it doesn’t work for the physician, staff, and patients, you will pay the price for a very long time. So start off right from the get-go, and get your priorities in order.
Figure 1 is a guide to help you prioritize the functions of a healthcare facility space — the Priority Pyramid:
The Physician: The doctor is the reason the facility, staff, and patients are there in the first place. Concentrate on eliminating steps and time between patients for providers. Often we find that managers/administrators start worrying about how long the doctor is in the exam room. It’s not their, or our, prerogative to tell a doctor how much time he or she should spend with a patient. The physician knows best. What we have discovered is that any lost time during the patient visit pales in comparison to the physicians’ lost time when the space design is not efficient for flow. If the doctors have to walk down a long hallway to a desk or counter space, or if exam rooms are far apart, the clinicians end up taking many steps that would otherwise be unnecessary. These steps equate to considerable lost time and lost revenue at the end of the day.
The Staff: When staff time is misused, either more staff members are required or staff members are not available when the doctor needs them, and the doctor’s time is misused.
The Patient: We have found that by concentrating on the doctor and staff flow patterns and time utilization, the patient benefits by the practice functioning more smoothly and running on time. Every patient wants to get in soon, get through quickly, and get good care — efficient space planning can help with all three.
Figure 1. The Priority Pyramid.
Everyone in the practice is important, and the priority pyramid is not a level of importance — after all, without patients there is no need for either staff or physicians. We all need each other. However, if the physicians’ needs aren’t met, their production isn’t optimized, and everyone pays the price. The physicians ultimately provide the care that produces revenue to keep the practice going.
Efficiency: It’s About People, Space, and Systems
It is not just about bricks and mortar; an efficiently planned space requires understanding the entire business — the functions, work processes, and flow involved, including:
Appointment scheduling templates;
Communication systems;
Staffing model;
Individual job descriptions; and, of course,
The doctors’ potential rate of seeing patients.
The last item on the above list is seldom given enough value and attention. How fast and how many patients the physician can see over a specific period of time dictates the workflow once the patient is roomed. This is vitally important. We say potential rate of seeing patients, which sometimes is far greater than the actual number of patients seen. When we discover the potential is greater than the number of patients seen, it’s a simple conclusion that the physicians’ production is not optimized, thus inhibiting the profitability of the practice and, most likely, patient service.
This doesn’t happen because the doctors don’t care or are not working hard. It generally means they aren’t working smart. They may be taking too many unnecessary steps or being interrupted excessively and unnecessarily. Sometimes they are simply doing tasks that could easily be delegated to support staff. Too often we assume we are working as fast as we can and doing the best we can, when in fact, there may be a way to streamline processes and work to ensure our facility maximizes the opportunity to do so.
Part of the problem is that all of us get used to working a certain way in our environment and seldom take a critical look at what we could do differently. When you are thinking about design modification or acquiring new space, one of the best investments you can make is to bring in medical design experts and healthcare management consultants to help guide the process. These experts will provide an objective and critical look at what you can do to streamline flow, improving efficiency, patient service, and profits.
Let’s take a look at the impact on a practice that just one system, specifically practice communication, can have when poorly organized and managed.
The Communication System
The communication system and habits surrounding communication throughout the organization must be examined when designing space. If the doctor and staff are walking all over the place to deliver instructions and orders, then their productivity will suffer. If a physician is interrupted during clinic sessions, he or she gets behind. If staff members spend precious time looking for someone, then their communication system is weak and time is wasted. The cost of a poorly functioning communication system cannot be easily retrieved, and the practice is likely to experience the following:
Patients are not going to be happy with delay in care.
Some staff will probably work overtime.
The physician and staff will have work that needs attention left at their workstation or desk at the end of the day, so they are already behind when they arrive at work the next day.
This is a recipe for ongoing stress, dysfunction, and loss in profits.
Why Existing Workflow and Space Must Be Evaluated
Existing workflow and space need to be evaluated so logjams causing a backup somewhere in the patient flow and the magnitude of those logjams can be identified. This allows solutions to be developed before any new design starts. The evaluation information is also used as a basis for the design.
By determining the magnitude of the logjams and workflow inefficiencies, projections are made that will predict the potential patient volume once solutions are implemented. This is your basic, old-fashioned time and motion study. The difference is that the time study should focus on the doctors’ time first, then that of the staff, and, lastly, that of the patient. Remember, patients will benefit from good doctor/staff flow, and their experience will be far more satisfying. All too often, practices focus time studies on how the patient or chart moves through the process, when the major problems lie in how the doctors and staff move through the system and how efficiently everyone communicates.
Humans adapt. So the longer a practice is in an existing space, the longer it has had to adapt to the space allocation and layout. What may have started out as a good facility plan for a small practice has turned into a major problem that compromises efficiency and profitability. The space becomes insufficient and inefficient for the practice after years of growth and change. The practice simply keeps functioning without looking at the high price the entire team is paying to stay where it is.
Perhaps closets have been turned into diagnostic spaces, workstations have been converted into exam areas, and so on, even though they are not in ideal locations and compromise work and patient flow. And because the practice slowly grew over time and humans adapt, the physicians do not realize the harm to production that the new flow is causing.
By evaluating the existing space and work/communication flow and projecting a potential new patient volume, the space, staff, and equipment needs of the new facility can be projected before the design process even begins. Then a more accurate projected cost can be developed. This is when changes can be made and plans can be altered. Then, if the budget is not in sync, adjustments can be made or production postponed before expensive design work begins.
Remember that the project should be focused on organizing and designing a practice tool that will serve you for years to come — not simply making an architectural statement.
Characteristics of Good Facility Design
One topic that is vitally important when designing an office is patient flow. Practices wonder which design creates a better flow: one-way (linear) flow or a patient flow where patients exit the same way they entered. We are huge proponents of the latter. It is human nature to try to exit a building the same way you enter. When patients exit the same way they enter the office, the space is familiar, they know where they are going, and they are far more at ease. It’s sort of like Dorothy in the Wizard of Oz and the yellow brick road and feeling in control.
When a practice has one-way flow, staff must constantly show patients the way out of the facility. This creates patient confusion, takes time, and can lead to chaos. When patients exit a different way than they enter, they feel lost and don’t really understand where they are in relation to where they started. This forces staff to escort patients out of the office and leaves them feeling a bit insecure.
Making One-Way Flow Easier
There are reasons a practice believes that one-way flow is the best course for its facility, whether it’s the nuances of the facility, the size of the practice, or the volume of patients. It has great appeal for cosmetic practices where patients who have just completed a procedure do not want to be seen by other patients coming into the office. Ultimately, the decision for patients to exit a different way than they enter is the owners’ to make. If you decide one-way traffic flow is best for your new or renovated facility, there are some steps you can do to make it easier for your patients:
Have good signage that makes it easy for patients to understand where they should go.
Get staff involved in how patient care and services will be managed without compromising patient flow or efficiency.
Patient Services and Satisfaction: Critical Factors
Most patient satisfaction surveys are conducted based on an encounter date and shortly after the visit. This means patients may be unable to give an opinion about the physicians’ clinical skills or accuracy of diagnosis and treatment plans because they may not know yet the outcome of their treatment. For this reason, surveys most often will cover the following points:
Whether they were seen on time;
Attitude of the staff and doctor;
Discussion of treatment options; and
Comfort of the office.
In this case, patient satisfaction is more about customer service, not outcomes. This gets back to the heart of the patient-centered practice. There is a payoff for functioning smoothly and efficiently. It contributes to a more satisfying patient experience. When your facility is working for you, the time spent with patients is more focused, allowing clinicians to strengthen the patient-physician relationship. At the same time, the entire practice team is more productive.
Improving The Patient Experience
By addressing the functions and needs of the practice, you will improve the patient experience. This provides another advantage: everyone in the practice becomes more efficient when the patient experience is improved. Here are a few ways your space can improve the patient experience:
Arrange the receptionist’s duties so he or she can welcome patients face-to-face as they arrive and not be talking on the phone or behind a glass window. This also pays dividends by hastening the check-in process and contributing to improved patient flow.
Develop an appointment scheduling template that coordinates with the time elements involved for staff and physicians during the patient’s visit. This ensures that wait times for patients will be minimized and bottlenecks are less likely to occur.
Design flow systems and space layout so patients do not backtrack or get disoriented during their visit as they walk the path of care.
Heighten continuity of care and patient service by using scribes or assistants in the exam room, preferably the same staff person that roomed and prepared the patient. This staffer should be able to perceive the physician’s needs during the visit. The same staff person will be able to provide any follow-up instructions or ordering of tests once the physician completes the patient visit. This eliminates the need for different staff members to ask the patient the same questions multiple times.
The Wow Factor
We believe strongly that in addition to clearly understanding the importance of design and workflow, the ultimate goal is to create an awesome impression for the patients. We call it the Wow Factor. It’s what makes patients feel they’re receiving an extraordinary experience. The Wow Factor impresses patients as they find themselves enjoying their visit from an aesthetic point of view. With the Wow Factor, patients feel they’re in a practice that’s a cut above the competition, and they automatically assume they are getting more for their money — including quality medical care.
The Wow Factor is our expression for going beyond the typical, traditional experience provided by most practices and clinics. And here is where we want to inspire and empower you with ideas, resources, and a fresh perspective.
To start, you must consider your patients. What are they like? Are they older folks who like to, or wish they could, travel? Are they immigrants who would appreciate a historic nod to their heritage? Are they young executives on the go? Most practices can’t put all their patients into one category, but your typical patient base will have some similarities and common needs and interests, and speaking to them through design will definitely wow your patients.
What Wows Your Patients?
Your facility design elements and layout are a big part of meeting the needs of patients and a tool in going the extra mile in showing them your practice is a best practice and convincing them they wouldn’t want to go anywhere else.
Walk in Their Shoes
So walk in your patients’ shoes, metaphorically speaking, and think about their needs and likes. Do those mothers need stroller parking? Do your geriatric patients need extra space for a walker and a smooth floor to push along, free from floor décor like magazine racks and potted plants that may pose a tripping hazard? If your patients are self conscious about the services they receive at your practice, can you give them additional privacy by not making all the chairs face each other in the reception room and having some tall plants between areas? Do spouses or other family members often attend visits? If so, how can you make their wait more meaningful and enjoyable? Would a silent viewing of a National Geographic program or healthy cooking ideas on a flat-screen television be appreciated?
The Three Components of the Wow Factor
How might you make your space memorable to patients and visitors? They should expect healthcare facilities to deliver comfort, good lighting, reasonable reading materials, and a pleasant environment, but you can give them an extraordinary experience without breaking the bank. You can provide interest and perhaps intrigue, and make their experience exceptional. It’s the Wow Factor (Figure 2), and it consists of three components that aren’t difficult to achieve.
Figure 2. The Wow Factor.
We highly recommend hiring an interior design expert with experience in medical facilities — ideally, someone whose work you have seen and admire. Whoever is selecting the design elements for patient areas needs to be briefed in the desired image of the practice and the patient demographics in order to make appropriate selections and recommendations.
Pop of Color
Providing a “pop of color” means providing a place for the eye to move, creating interest and intrigue that is neither overwhelming nor unsettling but just enough to be pleasing. Some ways to achieve the pop of color are through floral arrangements, bright mats on pictures (consider this with black-and-white photos), a small side table in a solid color, or accessories. If the reception room is color coordinated in cool shades of blue and gray, a pop of warm orange would make a statement. If done tastefully, it will not be overwhelming. Of course a youthful, energetic space like that of a pediatric or sports medicine practice may want more color and more “movement” than a practice focusing on elective services for women or a gastroenterologist. What’s nice about the pop of color is you can change it and give your space a whole new look without spending the money to totally redecorate.
Element of Surprise
This component of the Wow Factor makes the patient experience you provide truly memorable. Having a few rare ancient artifacts as accessories — perhaps set on a pedestal with museum-like lighting and an explanation of their origins — would certainly make most patients pause in surprise. How about a custom-designed metallic logo and practice name sign on the wall behind your reception staff area or an etched-glass wall feature that exhibits your mission statement? Tickle the ears with symphony music or a fountain. Elegant displays of a collection of shells or antique books or sports memorabilia, or providing a changing and nursing station that is luxuriously and generously outfitted to any mother’s needs and wishes could be just the element of surprise to wow your patients. Whatever you do, play to your demographic.
Touch of Luxury
This component of the Wow Factor really cinches the Wow. Impressing patients with something they consider a luxury will wow them and speak volumes as to the quality of care they receive at your practice and its value. It’s not necessary to overdo this element, just provide it where you can and where it makes sense. Talk with a local florist about having fresh flower arrangements delivered regularly in exchange for their business cards being next to the display, provide water bottles or a custom coffee station where patients can easily brew just one cup of whatever they prefer, a heated coat rack, or the changing and nursing room mentioned above. Any of these would fill this component of the Wow Factor in ways that will set your practice apart from the competition. A warm blanket for patients resting in a dental chair, a tote bag filled with the things your patients will need after their visit, and a luxurious bathrobe with your logo on the front given to cosmetic surgery patients are types of luxuries that speak volumes to patients and can be provided in a way that makes sense when planning your facility design and layout.
Your Facility, Your Future
Your facility is first and foremost a tool of your practice. It must meet certain performance requirements for your practice to perform at optimal efficiency and production — period. Beyond function, design, and ambience are important elements of the practice image and patient experience. A word from the wise — in this case Larry Brooks: “Get it right the first time.” If you are doing a redesign or moving to a new facility, carefully consider all the performance requirements this space must meet while accommodating projected growth. Get an accurate measurement of space needs based on the projected potential patient volume of each provider. And use the experts. Hiring someone whose expertise and loyalty work to your benefit can save thousands of dollars in the long run by retained revenue with optimized efficiency, not to mention avoiding costly moves and remodels that come too soon due to improperly planned spaces.
The Payoff
A healthcare facility designed with the goal of maximizing the providers’ time and skills will greatly contribute to a more efficient and profitable practice. Practice décor with the Wow Factor gives patients an experience that is a cut above the competition, increasing the perceived value of their visit.
Sidebar: Tips to Improve Function
Here are a few things you might want to consider when designing your space and determining how it will function for your business. These tips could keep you from making a mistake and help you improve patient flow and efficiency.
Organize the clinic around exam pods, a group of all the rooms (i.e., exam, doctors’ workstation, nurses’ station, procedure room) the doctors need while seeing patients. Reducing the physicians’ steps and lost time is a profit builder!
Base the number of exam rooms on hourly patient volume and exam room turnover time. There is no benefit to having extra rooms full of waiting patients who grow agitated.
Evenly distribute the physicians’ exam rooms across the hall from each other. This is far more efficient than having three or four on the same side of the hall — it saves steps and improves communication. Align exam rooms with the short end along the hall, which means rectangular rooms will be designed to be long as you enter. This brings doorways closer to one another on the hallway. These two ideas reduce the distance the doctors, staff, and patients walk, saving time and increasing productivity.
Plan to have every exam room set up exactly the same (unless usage dictates otherwise). This allows the doctors to know exactly where everything is and reduces the chance that they will have to spend time searching for things. This also helps staff stock the rooms quickly because all things will be in the same place in each room.
Recognize the importance of hallways. Much like streets of a city, hallways in circulation paths must be wider in higher traffic areas where people are coming from the reception room to enter the clinic or are lining up for checkout in an area where people are passing by. It is recommended that in these areas the space be one-and-a-half to two times as wide as the typical hallway, which is usually five feet.
Place nonpatient areas further away from the reception area. By placing the staff lounge and other nonpatient spaces further from the reception area, you decrease the need for patients to walk past these areas and bring patient care areas closer, reducing the distance patients and staff have to walk within the practice. This saves time, which increases efficiency and production.
Excerpted from The Patient-Centered Payoff: Driving Practice Growth Through Image, Culture and Patient Experience by Judy Capko and Cheryl Bisera.