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    Form and function: Designing an office space that works

    Office redesigns that ramp up productivity, efficiency


    Susan Wilder, MD, family physician and co-owner of LifeScape Medical Associates in Scottsdale, Arizona, takes pride in the fact that a patient told her she feels better just walking in the door of her custom-designed practice.
    Is your office space performing at its best? Try experiencing it the way your patients do, by coming in through the waiting room. Notice the condition of the walls, flooring, and lighting. Breathe in the air.

    Then walk the halls. In the exam rooms, front desk, and business office, how easy is it to find the tools and equipment you need every day?

    If you've noticed some things you would like to change, you have already taken the first step toward redesigning your office. You have started making a list of design issues to address.

    We talked to architects, designers, and physicians about redesigning your office to make it more efficient and productive as well as more pleasant and comforting for patients and employees. From simple, free do-it-yourself updates to major renovations, here's the advice you need to improve the appearance and functionality of your waiting areas, corridors, exam rooms, and more.

    DESIGN CAN OPTIMIZE PRACTICE FLOW, IMPROVE EFFICIENCY


    LifeScape uses minimal overhead flourescent lighting.
    Cosmetic aspects of an office design or makeover can make a positive impression on patients and immediately put them at ease in stressful situations. While the design of LifeScape Medical Associates in Scottsdale, Arizona, is aesthetically pleasing, it was also designed for optimal patient and clinician workflow.

    "Our nurses' station is core central," says LifeScape co-owner Susan S. Wilder, MD, a family physician in Scottsdale, Arizona. "It's right in the middle. It's wide open. There's a lot of space and a lot of ability for doctors and medical assistants to communicate between patients. Doctors will be out there with their computers, so you can accomplish a lot in a short period of time."

    The station contains what Wilder calls "tackle boxes" for acute wound care, eye care, and anaphylaxis. "It just makes it easy to grab and go and not have to be looking around for a tray," she says

    Richard Haines Jr., an architect and president of Medical Design International in Norcross, Georgia, says that any redesign must address issues with poor traffic flow, chronic inaccessibility of supplies, and cramped workspace.

    These improvements require not just a careful eye but also some thought and creativity, Haines says. You need to identify bottlenecks and their root causes, and come up with practical solutions.


    Exam rooms have family benches.
    For example, as you walk around an exam room, do you have to step around the trash can each time? Do you always have to worry about exposing the patient when opening the door? If so, you may want to remount the door so that it opens toward the exam table, so that the patient can't be seen from the hall.

    As a general rule, consultants say that all supplies, equipment, and staff should come to you, rather than you going to them. "You work out the work flow so that you are not running all over the place," says Charles M. Kilo, MD, chief executive officer of the GreenField Group, a healthcare practice consulting and redesign firm in Portland, Oregon.

    One question to ask, he says, is: "How many steps do you have to take?" In a doctor's office, staff members are always on the move, performing the same set of tasks again and again, so any reduction in the number of steps they take on each task will produce significant gains in efficiency.

    • Minimizing waste. Marc Margulies, principal at Boston-based Margulies Perruzzi Architects, designed a 5,000-square-foot urgent care facility for Fallon Clinic, a 250-physician, multispecialty group practice in Central Massachusetts. Margulies and Fallon Clinic applied Lean management techniques in the office design. Derived from the manufacturing industry, Lean philosophy is "the systematic identification and elimination of waste and the implementation of the concepts of continuous flow and customer pull," according to the Kaizen Institute, a Swiss consulting firm.

    During a weeklong study, Fallon Clinic and Margulies charted every step the physicians, assistants, and office staff would take to determine how the waiting room, hallways, and exam rooms should be designed for minimal waste.

    Margulies' team designed the space using a "hub-and-wheel" design with the exam rooms on the perimeter and workstations as an island the middle where physicians, nurses, and office staff work with electronic charts and papers and consult each other. Exam room doors also have opaque glass so medical assistants can see whether a physician is with a patient.


    A live tree grows out of the ground in LifeScape's waiting room.
    "If the doctors and nurse practitioners are the most important people to keep as efficient as possible, then the trick is to put them at the hub of the wheel, not at the perimeter of the wheel," says Margulies. But don't allow the hub to consume too much space. An ideal family practice should still have 2.4 to 2.7 exam rooms per practitioner, Margulies recommends.

    A typical family practice office visit consumes approximately an hour, with 33 minutes spent on direct patient care, entering information into the chart, and seeking payment for services. The rest of time is spent waiting. The clinic's improved layout, along with other workflow and patient scheduling changes, cut 29 percent out of the waiting time, down to an average 42-minute visit time.

    • Simple changes, major payoffs. Smaller changes can also make a difference, says Elizabeth Woodcock, an Atlanta-based medical practice consultant and author of the book Mastering Patient Flow.


    The hanging fabric triangles in LifeScape's children's waiting area represent kites.
    For example, if you have a long hallway with a bend in it, installing a convex mirror will help staff see whether a chart has been placed in the chart rack without having to walk there, she says. And if the nurses' station is far from the exam room, the nurse can take a computer cart with him or her rather than running back to the station to enter information.

    The same applies for equipment such as photocopiers and fax machines. Instead of having receptionists walking 20 feet to photocopy the insurance card each time a patient comes in, Woodcock recommends installing a desktop photocopier right beside them. The goal, she says, is to have equipment so close that a staffer only needs to swivel his or her chair to reach it.


    Paint colors are a visually appealing and inexpensive design change.
    • Exam rooms. Exam rooms become much more efficient if each one has the same layout. When equipment is always in the same place, no matter what room, "the physician doesn't even have to look when reaching for a computer keyboard, otoscope, or whatever else," Woodcock says. In some cases, this may take a little remodeling, such as moving cabinets, but you will be rewarded with greater efficiency.

    Fallon Clinic is redesigning one of its family practice offices using a Lean principle applied in designing its urgent care center: Every exam room is identical, with the sink, light switch, and blood pressure cuff all in the same location. The cabinets contain the same supplies in the same locations, so physicians, midlevels, and assistants know where everything is regardless of which room they're in.


    LifeScape's open workstations encourage clinician communication.
    Changes in the practice's overall layout can enormously improve efficiency. Haines worked with a solo primary care physician who had three exam rooms, one of which was next to the checkout desk, where patients always stopped him for a chat. When the third exam room was relocated away from checkout, Haines says, productivity improved from 40 patients to 70 patients per day.

    CUSTOM-DESIGNING A PRACTICE OR UNDERGOING A MAJOR REDESIGN

    There may be one or two times in your career when you have an opportunity to custom-design a new practice or undergo a major redesign. Those who have done it advise others to take full advantage of the opportunity to optimize efficiency while also enhancing the environment for patients and staff.


    LifeScape's open workstations encourage clinician communication.
    Wilder's practice has six physicians and 12 exam rooms. Her husband, Robert Wilder, co-owner of the practice (nonphysicians can be nonmajority co-owners of medical practices in Arizona), worked with a professional healthcare design firm to create an office space that was relaxing for both patients and staff. When they started the planning, "We had a vision of a healing environment," Susan Wilder says.

    Working closely with his wife, Robert carried out much of the planning, which included small touches such as upholstered benches in exam rooms to accommodate patients' families.

    There were some problems to work through, Robert says. The practice bought a pre-made shell, which meant that the interior columns weren't built to their specifications. The columns forced them to build exam rooms a foot shorter than planned. In the end, everything worked out, and the result is a well-designed and aesthetically pleasing space.


    LifeScape's break room lets in plenty of natural light.
    "Everything was developed to bring nature indoors," Robert says. The office uses natural material such as wood, stone, copper and plant life. The multi-level curved ceiling symbolizes clouds, and hanging over the children's area of the waiting room are colorful cloth triangles to represent kites.

    "Put yourself, at all times, in the patient's shoes," Robert says. "See the office through the eye of a patient, who will invariably be stressed, and what can we do, at every step, to minimize that stress and make it more positive."


    Designing by the dollar
    • Redesign solves patient overcapacity issue. Rainbow Pediatric & Adolescent Medicine, a three-physician practice in Plattsburgh, New York, used its two oversized waiting rooms to solve a patient overcapacity issue. Prior to the renovation, Rainbow's waiting rooms for sick and well patients were each 500 square feet, but due to its tiny building lot, it had no alternative but to reshuffle the space it had, says David Cohen, MD, the lead physician in the renovation. The remodeling was performed in stages, with each section walled off, so that the practice could continue seeing patients. First, one waiting room was remodeled into three waiting rooms for well, sick, and teen patients. The second original waiting room was remodeled into a new reception area, business office, and triage. Then the reception area was remodeled into two new exam rooms.

    To conserve space in the exam rooms, shallow cabinets were hung on the walls. "It's a very modern look," Cohen says, adding that teen patients in particular were enthusiastic.

    Cohen says the project cost was $400,000, or $80 a square foot. "That's a bargain," he says, compared to putting up a new building, which would have cost an estimated $1 million.

    FINDING MORE SPACE WHEN YOU'RE ON A BUDGET

    Many doctors' offices are plagued by lack of space. Exam rooms may be too tight to carry out an examination without bumping into things, much less to fit a parent in the room. Similarly, staff areas may be so cramped that it is difficult to work efficiently.

    The obvious solution, adding a wing or building from scratch, is not an option for most practices. "It's terribly expensive to start from scratch," Kilo says, estimating the cost at $100 a square foot in some markets.

    Moving walls is usually not an option when you're not in the midst of a major redesign. "You are not going to rip down drywall and expand it," Kilo says. Moving walls can be expensive, disruptive, and, in many cases, impossible, because there's no place to expand to.

    Therefore, sometimes the only viable solution is to create more space within existing space.

    • Creating space. "You have to look for space efficiency," Kilo says. Items and functions that are not absolutely necessary have to be removed.


    EHRs can save space, create efficiencies
    One obvious target is the sink, which is usually just used to wash hands. Hand-washing could be done at a communal sink down the hall, but that involves extra steps. Kilo prefers keeping the sink but making it smaller, the size of a wet bar.

    Another target for creating space is exam room cabinetry, which can be overly generous. When you open up the doors, "you may find all sorts of things that you don't need," Kilo says, "[such as] a year's supply of tongue depressors, forms that are 10 years out of date." An alternative to removing cabinets is replacing them with shallower ones.

    Many doctors now bring computers into the exam room to show patients radiology images or to enter notes directly into the chart, which does away with the need for a dedicated workspace for these functions. Articulated arms, costing $500 each, can be attached to the walls, pulled out to hold a laptop, and pushed back against the wall when done.

    At LifeScape in Arizona, Susan Wilder is considering selling the practice's bone-density machine—which is not contributing significant revenue—and leasing the space to other healthcare providers. Because the Wilders made sure their exam rooms are all designed identically, converting the room will be simple.

    "You can set up any room for whatever specialty you are," Susan Wilder says. "You want the spaces to be flexible."

    • Repurposing existing space. You might want to think about converting private doctors' offices, which are rarely used, to free up room for other activities.

    "The concept of having a consult done in a doctor's [private] office is very old world," says Margulies, noting that most of the family physicians he's consulted with needed office space only for private dictation, to consult with nurses or assistants, storage, and a work surface. "What they need to be is at center of action."

    One area in particular that is often in need of space is the business office, says Jain Malkin, the San Diego-based designer who helped the Wilders design LifeScape and who has written several books on medical office design.

    In a business office, "there may only be 3 feet by 2 feet of space in the middle of the room," Malkin says. "That's not a realistic amount."

    With a little imagination, she says, you may be able to find more space by converting whole rooms to a new use, whether it is more business space or an extra exam room. A dedicated dictation room may no longer be needed if you buy noise-cancellation microphones allowing dictation anywhere. You could eliminate a phlebotomist's station by drawing blood in the exam rooms.

    Similarly, you may be able to take space from part of the waiting room, or eliminate the waiting room altogether. "The new idea is to move patients directly into the exam rooms rather than leave them in the waiting room," says Mike McKay, a partner at Morrison Kattman Menze, an architecture firm in Ft. Wayne, Indiana.

    Changing the appointment schedule also may free up space. Haines says a doctor in Texas wanted him to expand his waiting room because it could get too crowded. It turned out that in the first two hours of the day, the doctor scheduled twice as many patients as he could see, which started the log-jam that backed up the waiting room for the rest of the day.

    At the end of the day, once you've looked at other areas in which efficiencies can be gained, it may turn out that you don't need all of the additional space you thought you did. For example, the reason for a shortage of exam rooms may be that physicians are not sharing them.

    "It's ridiculous for physicians to insist on their own exam room," Kilo says, when patients are backed up while rooms lay empty.

    SMALL CHANGES CAN MAKE A BIG DIFFERENCE

    You don't have to spend a lot of money to make significant improvements (see "Designing by the dollar," page 18, for ideas for every budget). LifeScape's office includes high-end features such as a tall granite water feature in the lobby and a 14-seat hardwood conference table. But two of Susan Wilder's favorite features are the least expensive: the color and the lighting.

    "Paint can change the ambiance and improve the feel of the place," says Wilder, whose office is decked in colors such as lime, orange, and eggplant. "Our designer used paint colors in a way that makes the place very warm, very inviting, very cool-looking. I told her, 'I can't afford fancy artwork.' She was creative with paint and light."

    Although there is the inevitable overhead fluorescent lighting in areas of the building, the waiting room is flooded with natural light from windows and skylights. For artificial light, Wilder's practice includes a variety of track, recessed, and pendant lights.

    Medical office designers say that the appearance of your practice can impact a patient's overall impression of your business.

    "If you're sitting in a dingy old waiting room, you've got to think, 'This doctor doesn't have pride of place,' " says Haines. "You'll get a lot of mileage out of a little work."

    The easiest thing to do—and probably the biggest bang for the buck—is to refurbish. Tear down the dated wallpaper and add a fresh paint color. Throw out dead plants. Have the upholstery professionally cleaned every six months.

    YOU BENEFIT, AND SO DO YOUR PATIENTS

    Office redesigns and enhancements are based on the idiosyncratic needs of each practice and cannot be produced by cookie cutter. The design solutions you and your staff develop to address efficiency and productivity issues will also create a more pleasant patient experience.

    "Just the other day a patient told me this is the most beautiful place she's ever seen, that she felt better just walking in the door," says Susan Wilder. "It's very relaxing, and patients appreciate that."

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