The healthcare industry is at the forefront of a facilities transformation on an unprecedented scale. The traditional regional and national community health systems are announcing wholesale campus redesigns. Large single and multispecialty medical groups are readying their organizations for specialized ambulatory care center builds, while medical device and equipment vendors are adjusting strategies to be on the leading edge of an expansive transition of care to physician-driven, specialized ambulatory medical and surgical facilities requiring improved productivity performance.(1)
Hundreds of billions of dollars will be invested in the growth of comprehensive and specialized ambulatory care strategies wrapped in high-performing, “smart” ambulatory care facilities. The era of the generalized multilevel “medical arts” office building housing multiple small, unaffiliated, and independent medical practices is dwindling.
The future is “smart” medical, surgical, restorative, and integrated ambulatory care strategies wrapped by innovative facility designs built affordably for a high-performing, continuous care model and method innovations.
The questions that loom large over the thesis presented are: “What’s a smart ambulatory medical facility?” and “What is the key to its success?” While both questions are answered here, the emphasis is on the second question. The position taken is that the successful integration of smart strategy wrapped in smart facility design and construction is feasible only with the active engagement of well-prepared physician leaders.
ELEMENTS AND OPERATIONAL CHARACTERISTICS OF THE SMART AMBULATORY MEDICAL FACILITY
While medical facilities are classified for purposes of financial statements and tax filings as “fixed assets,” their functionality is far from static. Smart ambulatory facilities are living, breathing “beings” built and operated for high performance. Elements and characteristics of high-performing smart facilities follow:
They are branded and marketed as destination strategies. They aggregate multiple clinical specialties or subspecialties under one roof (and brand) to facilitate high-performance, clinical, and strategic collaborations and superior patient experiences.
Patient care collaborations are enhanced with sophisticated clinical diagnostics (laboratory and imaging) and procedural and surgical services, creating significant financial margin expansion opportunities for the users.(2,3)
The comprehensive ambulatory care destination image is bolstered by specialty-specific physical/restorative therapies and urgent care serving general and specialty-specific cases.
Designs favor “team care” and efficient provider substitutions, and physicians and advanced practice providers work collaboratively.
Facilities are geared to the utilization of extended hours and days.
Overnight stay abilities may be available to extend surgical case productivity later in the workday.
Internal designs and materials applications facilitate ease of facility reconfigurations to accommodate clinical services reprogramming and specialized clinical technologies applications.
Information technology configurations and installations permit intraoperative communications between and among providers, including a shared electronic medical record, practice management platform, and virtual care delivery spaces.
Patient parking designs recognize the mix of patient care needs, such as urgent care, periodic visits, chronic care utilization, and physical rehabilitative care.
A facility concierge welcomes patients, directs them, and aids them in finding patient service locations.
Providers and the community share conference and meeting room facilities.
“Off-stage” provider working area designs minimize the nonrevenue production spaces while facilitating patient care collaborations.
Exam room “pod” designs optimize provider efficiencies while minimizing wasted space.
Waiting room space is re-engineered to accommodate high-efficiency patient flow management.
THE PHYSICIAN LEADERS’ ROLE
Why should physician leaders be involved at the front end of a complex smart ambulatory care facility design and build? Simply because they bring clinical care “manufacturing experience” to the table, together with direct experience in specific clinical programming and the wherewithal to access the specific care management know-how they don’t possess.
Physician-leader involvement improves the odds of asking the right question at the right time. Case in point: With the ambulatory facility build rendering provided for the Hudson Medical Center (Figure 1), the concrete floor pour for the ambulatory surgery center was three days away. A doctor closely affiliated with the project went to the space for one final look. The question raised with the onsite construction supervisor was, “What about floor vibration control? We’ll be doing microscopic-assist surgeries in two of four ORs.”
The response from the construction supervisor was a blank stare. Fortunately, the concrete was not on site yet. The project engineering firm was contacted, and adjustments were made. Disaster averted.
How should physician leaders ensure the success of the smart ambulatory center design and build? Valuable contributions shape design, architecture, engineering, functionality, materials, clinical technologies placement, patient flow, and provider and staff productivity. The best project managers will know when to tap the assigned physician leaders for their contributions.
Figure 1. Hudson Medical Center is a 160,000-square-foot ambulatory specialty center that houses healthcare services provided by nine independent primary care and specialty medical and surgical groups. It also offers advanced diagnostic imaging services, sports medicine and physical therapy programming, and a comprehensive urgent care service. The center includes a 24,000-square-foot, physician-owned, multispecialty surgery and procedures center.
PHYSICIAN LEADER’S WORK PLAN CHECKLIST
Before proceeding with the Physician Leader’s Project Checklist presented below, we believe a word of caution is in order. The physician leader’s accountability is to the project’s overall success, including the connection of participating providers’ input to the project. The physician leader is cautioned to avoid leaning too far toward becoming the providers’ advocate and provocateur on the project, i.e., the one assigned to make sure all the doctors “get what they want.” Leaning too far in this direction will quickly sour the team on having “the Doc on the job.”
It’s helpful to remember that on a complex build, a range of highly educated and experienced professionals value teamwork and deserve respect. While the operating room may be the surgeon’s domain, the construction trailer is the project supervisor’s.
So, what defines the physician leader’s role in building a smart ambulatory medical facility? The following checklist frames the job.
1. Clarifying vision, purpose, and “brand” positioning.
The providers’ view of the facility’s mission, vision, and strategy, including how it should be positioned in the “mind’s eye” of the end users, patients, and providers, should be clear.
2. Translating vision to function and performance, including the potential growth and expansion plans.
The providers’ voices are brought to the table at the front end of the project. For the physician users, physicians often view smart ambulatory facility designs and builds as “the opportunity to finally get it right!” Getting it right translates to high productivity, high efficiency, and a superior patient–provider experience.
3. Bringing clinical programming to life within the early phases of facility concept design and schematics production.
Every clinical program is profiled for patient service volumes at the highest expected levels, along with understanding how staff, providers, and patients will move through the facilities at optimized production performance.
4. Considering key patient characteristics by clinical program, age, gender, mobility, physician, behavioral conditions of note, and typical return-to-visit profiles.
Patient type and physical function variations influence facility design. For example, a high proportion of elderly patients increases the number of walkers and canes; bariatric clinics require special seating and spacing of larger chairs; orthopedic clinics require easy access for patients with mobility limitations; clinics that serve adults and pediatric patients may require waiting area separations.
5. Providing specialized, in-office diagnostics and treatments.
Specific specialties, such as ophthalmology, will require “special testing” rooms within the clinic setting. Moreover, eye clinics will not need or want natural lighting in exam rooms. Windows in the clinic space are not only unnecessary but also unwanted.
6. Addressing specialized pharmaceutical inventories and storage requirements.
Some specialties have little need for onsite pharmaceuticals, while others are high consumers and require refrigeration and high security. Others may have specialized needs, such as compounding, which requires laminar flow cabinets and necessitates specialized ventilation applications.
7. Considering patient-encounter turnover rates.
Daily clinic volumes per provider differ markedly by clinical specialty. While general internists may see 25–30 patients daily, retina specialists may see 70–80, including eye injection patients. Within ambulatory surgery center environments, specialized surgery/procedure case throughput can be as high as cases. The robotics suite may be optimized for six cases per day.
8. Accommodating urgent/emergent care programming and strategies.
Urgent care may be designed for general or specialty-specific usage in an ambulatory center, such as orthopedics. By design, urgent care departments will require key clinical adjacencies, such as imaging diagnostics, laboratory, and medicine. High-security rooms may also be required.
9. Identifying onsite surgical and procedural room services, especially those requiring complex designs and construction, space, power, and water requirements.
Ambulatory surgical centers command the highest construction costs per square foot. Equipment costs are also high, especially if robotic-assisted surgical programming is included in the plan. Designs for patient waiting and pre-/post-procedure care must facilitate efficient case turnover rates. Case turnover rates vary considerably depending on the clinical specialty, case type, and proficiencies of the practitioner.
10. Accommodating emergency transfer requirements.
Depending upon clinical specialty strategy, including urgent care and surgical care programming, accommodating emergency transfers may require specialty designs and construction, including special building access points for specialized transfer vehicles and first responders.
WHEN PHYSICIAN LEADERS SHOULD BECOME INVOLVED IN A FACILITY BUILD
Physician leaders should notify their organizations that they will be involved and active in any medical facility strategies. The time for involvement is at the earliest possible opportunity, beginning with conceptualization. The rationale for physician leaders’ participation is the assurance that the provider’s voice is “at the table.” The goal is a “smart facility.”
But what’s the first step for the physician leader? The first step is organizing the checklist, as provided here. It serves as the roadmap for the work ahead. It is a good idea to give the checklist to all principals involved in the project, including other physician leaders. Doing so will set the stage for effective project management.
Physician leaders who become involved in complex facility designs and builds should be prepared for a “Rubik’s cube”— a load of puzzles and problem-solving activities. With larger builds, upward of 100 or more skilled workers may be on the job on a given day, each with a specific task to do. The physician leader must weave in and through the “construction ballet,” being prepared for on-the-fly decision-making. As within the operating room, it’s hard to stop once the dance starts.
References
Zismer DK, Schwartz GS, Zismer ED. Ambulatory Specialty Center Construction. Minnesota Physician. 2022;XXXVI(3). https://www.mnphy.com/0622-cover-two .
Zismer DK, Schwartz GS, Zismer ED. Finding the Financial Margin Expansion Leverage in the Medical Practice. Healthcare Administration Leadership & Management Journal. 2023;1(1)17–21. https://doi.org/10.55834/halmj.6064036896
Zismer DK. Spare the Prep and Wreck the Building. Outpatient Surgery Magazine, March 2023.