Designing and Constructing Your New Practice Environment to Take Your Practice into the Future

This article is the third part of a three-part series.

The following article is the third in a three-part series that will help medical practices go through the proper process to determine if a new facility is needed and, if so, to create a new practice environment. The series follows the following outline:

• Practice Assessment

  • Do an assessment of your current practice to make sure you do not have logjams built-in to your current practice flow. Logjams can be identified that could change the direction of your overall practice needs. These logjams could be in the form of too few staff to handle the volume of patients the provider can see, mis-allocated staff or equipment, IT (electronic health records [EHRs], communications, appointment template, etc.) slowing the flow, etc.

  • Verify any proposed growth to the practice providers.

  • Identify the need for new services.

• Space Needs Assessment

  • Quantify the amount of space needed to support the new practice environment operating at peak efficiency and patient volume, with new services and providers to be added.

  • Make sure to know parking needs of practice. If your patients cannot park, they will not show up.

  • Evaluate your current facility versus a new practice environment.

• Design the New Practice Environment

  • Design it right the first time based on the practice and space needs assessment.

  • A good design costs the same as a bad design to construct, but pays dividends for the life of the facility.

Designing a new practice environment is similar to doing surgery on a patient, in that there is a process that needs to be followed; several team members play specific roles; and the keys to success are understanding the outcome goal, and applying knowledge and experience to reach that goal. The following article will address the process and the roles of each team member in creating a patient-friendly, efficient practice environment.

The Design Process

As covered in the first two parts of this series, the process of designing your new practice environment starts when you begin assessing your current practice operations and space to determine if a new facility is needed. This is when you begin to develop good patient, doctor, staff, and information flow concepts that drive the space needs and will drive the planning of your new practice environment.

Understanding how your new practice environment is to function prior to beginning planning is the key to getting a plan that is right for your practice and the first step in the design process. This is where the medical space planner comes in. This specialist in practice flow and planning guides your assessment, space needs, and planning of the new practice environment. This is different than the role of the architect, which we will cover later in this article, in that this team member’s focus is mainly on the operational characteristics of the practice environment, following the adage “Form follows function.”

The medical space planner will guide your practice in understanding:

• How processing a patient through the practice affects the layout;

• How equipment and communication systems need to be planned to best use the providers’ and staff members’ time;

• How the positioning of nurse stations and check-out areas help in patient flow; and

• How the plan layout will improve patient privacy and provider productivity.

The output of the medical space planner’s work will be operational flow diagrams, floor and site plans, and equipment information.

The following are illustrations of how the operational flow concepts are implemented in the planning of the practice environment.

Practice Flow Diagram

The practice flow diagram (Figure 1) illustrates the beginning of the plan concept and how it will address the space needs and flow of people through the building. This diagram is an important step in the design of your facility in that it quickly illustrates adjacencies and volumes of people moving through, and identifies pathways that will need to be wider to avoid logjams.

Figure 1. Practice flow diagram. Arrows indicate there will be 12 patients per hour (PPH) entering the waiting room and clinic each hour.

Notice in this practice flow diagram of a small ophthalmology office (building shape was already determined) that the arrows indicate there will be 12 patients per hour (PPH) entering the waiting room and clinic each hour. This lets you know those pathways will need to be wider than the six PPH entering each exam pod hall of the doctor. This pathway can be more narrow, but still wide enough for wheelchairs to pass.

As practices get larger and more complicated, the flow of people does as well (Figure 2). The arrows indicate that the flow of patients will be divided in two directions, but that they will also need access to the same areas. In this diagram, areas that will need to serve both clinical and cosmetic needs were quickly identified and became the organizing points of the plan concept. But if one of these areas was located where it caused either patients, staff members, or doctors to walk too far, the diagram would quickly identify that and allow the concept to be redirected early on in the design process.

Figure 2. Practice flow diagram of a larger dermatology practice that has both clinical and cosmetic services. Arrows indicate that the flow of patients will be divided in two directions, but that they will also need access to the same areas. PPH, patients per hour.

Initial Practice Plan

Once this type of diagram is approved, the next step is to further develop the planning concept and create a to-scale initial practice plan. “To scale” means you would be able to measure a space on the plan with a scale and know how wide or long a certain space is. This plan can either be done by hand or computer with computer-aided design software. It will reflect not only the flow and adjacency concepts developed in the practice flow diagram, but also the space needs assessment as well.

This is why the review and approval of the space needs assessment and practice flow diagram are so important, because if the idea or space is not included in those, it will not be carried on into the development of the initial practice plan. The initial practice plan shown in Figure 3 is of the same practice shown Figure 1.

Figure 3. Initial practice plan of the same practice shown in Figure 1.

As you see, the flow and adjacency concepts are now more defined, and the plan is a reflection of the concept work done during the creation of the practice flow diagram. Hallways around the check-in and check-out areas are wider, and the hallways of the doctors’ pods are narrower, but still five feet wide to accommodate wheel chairs and passing traffic.

The patient flow leads the patients in and allows them to exit along the same path.

The initial practice plan shown in Figure 4 is of the dermatology practice flow diagram shown in Figure 2. Again you can see how the adjacencies are kept, but some things, such as orientation of the locker area and the addition of an exercise room and workstation for the estheticians, are adjusted depending on the space needs and design aspects of the building and plan.

Figure 4. Initial practice plan of the dermatology practice flow diagram shown in Figure 2.

In both of these examples, several trends are evident:

• Each provider sees patients on an independent hall. This hall is referred to as a “pod.” This pod concept is very successful in locating doctors in a quiet, less-congested area with few distractions to allow them to be as efficient and productive as possible.

• The patient flow leads the patients in, and allows them to exit along the same path. They pass the check-out counter as they enter, and generally the patients have to make no more than three turns going to or coming from the exam room. These items are key to allowing the staff and doctors to stay on track. People tend to exit a facility the same way they enter, so using this natural tendency in planning the facility gives the staff and doctors the ability to get to the next patient quicker.

• All the exam rooms are the same size and layout, unless a room doubles as a minor procedure room. This is important so that the staff and doctors do not have to reorient themselves every time they enter an exam room or search for equipment/supplies, which takes time and will eat away at the overall patient volume the doctor can see daily. You have probably heard or will hear that it’s better to mirror-image the exam rooms so you can place the sinks back-to-back from one exam room to the other to save money. The patients seen with the saved time having all exam rooms the same will more than pay for any perceived added cost of not having the sinks back-to-back.

Once this initial practice plan is developed and discussed with your medical space planner, take your time in reviewing it. This review process should include all doctors, management, and staff members. At this point in the process, all comments should be gathered and discussed. The initial practice plan will need to be revised to address the comments you and the medical space planner feel are beneficial to the layout. Once the revised initial practice plan is developed, it will need to be approved by you to allow the medical space planner to proceed to the next phase—final practice plans.

Final Practice Plans

At this stage, the plan is set, and the task is to begin coordinating the ceiling and cabinetry design to promote good patient path cues, coordinate the equipment layout and electrical requirements, and dimension the plan. The work becomes a series of plans that are much more detailed. The following is a list of plans/information that is typically in a set of final practice plans:

1. Dimensioned floor plan

2. Equipment/electrical layout plan

3. Medical equipment information manual

4. Ceiling layout plan

5. Cabinetry elevations

6. Comfort zones diagram

7. Operational flow manual

Figure 5 shows an example of an electrical/equipment plan of the ophthalmology plan illustrated earlier. In support of this plan, the medical equipment information manual, which is prepared by the medical space planner in coordination with equipment vendors, contains information such as size, weight, and mechanical/electrical requirements of each piece of equipment. The medical space planner uses that information to size the space and place the equipment properly. Later on in the project, the engineers will use that information to properly provide the necessary electrical, mechanical, and structural elements for the equipment.

Figure 5. Electrical/equipment plan of the ophthalmology plan.

The ceiling and cabinetry layout and design are critical in tying the planning, communication systems, and flow concepts together to create the smoothly flowing, efficient, and productive new practice environment. Because two-dimensional drawings like the one above are often hard for the end user to visualize, the medical space planner or architect may develop a three-dimensional computer walk-through video to better illustrate the ceilings, cabinetry, and plan layout.

Figure 6 shows an example of one of the frames of this type of computer walk-through. In this shot, you are exiting an exam pod and looking back across the nurses’ station toward the check-out counter. The waiting room can be seen through the glass in the door to the left of the check-out counter.

Figure 6. Three-dimensional computer walk-through video.

During the final practice plans phase of the project another team member, the architect, may begin his or her work to coordinate the inside flow and planning with the architecture of the exterior if it is a new facility or a renovation to an existing space. This will be the beginning of the last phase of drawings for your project—construction documents.

Construction Documents

At this point, all medical planning and operational flow decisions have been made, and the general architect takes over from the medical space planner and develops the numerous details and building sections, engineering, final material selection, and specifications that will be used to guide the contractor in building your new practice environment. As will happen throughout the design process, as the design of the practice environment gets further and further developed, there will be tweaks and clarifications. The medical space planner will stay involved to address any of these that may affect the flow of the new facility.

This set of documents will be used to request bids from contractors if that is the process you choose, used to submit to the building code officials for review and permitting, and, finally, used by the contractor chosen to build your new facility.

Conclusion

We hope you enjoyed this series of articles on the proper process to first determine if there is unmet potential in your practice, then to identify the needs to achieve that potential, and then to understand the planning and design process that should be followed. The importance of following an operational process cannot be stressed enough. Medical practices are very complex, and to create a new facility that will best support the doctors, staff, and patients of your practice is a complicated task. Without the operational focus, decisions are often made on misguided information and cost the practice in lost opportunity every day over the life of that facility.