Facility Strategies to Support Integration: Facility Location and Design

There may be a desire to locate medical facilities in small rural communities that feed your hospital, but this can become an economic trap for hospital leadership. It is costly to place physician practices in small feeder communities; a midlevel strategy is economically more efficient. Or, having no facility may need to be considered.

Locating facilities in more desirable and growing areas of the community addresses the possibility of competitive organizations building facilities in your community, such as a primary care office or walk-in/urgent care facility, or both. Their goal will be to place operations in locations that will help them develop a foothold in your market and expand managed care contracting in your region.

Each market will have its own historical issues. Small communities that feed your hospital might have been served for many years by a local physician, and the community may expect this level of service to continue. However, in today’s mobile society, the patient volume may not be there to support a viable practice. Service-minded leaders will move to fill this gap without understanding the economic consequences of this venture.

Facility Design

Not all physician specialties are equal when it comes to facility needs and design. For the most part, primary care has similar designs, regardless of specialty type. However, as the number of physicians in a location increases, the design of the facility must change. The following is a discussion of the common components that should be considered for solo practices as well as multi-physician, single-specialty practices.

Solo Practices

Solo practices still exist in many communities, both large and small. Such practices, whether family practice, internal medicine, or pediatrics, share several common design elements:

• For a primary care solo practitioner in an office practice, it is not unusual to have three exam rooms and a procedure room. Two exam rooms could be used for the routine movement of patients while the third room is used for injections, ear lavages, blood draws, and possibly EKGs. The procedure room certainly would be used for endoscopic work, lacerations, dermatology procedures, and, possibly, observation needs.

• Unless the practice is very robust and remote to laboratory services, waived testing should meet the needs of the practice. Radiology services are too costly to provide.

• For maximum efficiency, the nursing and front scheduling staff should be in close physical proximity—not separated by a hallway. This allows efficient communication to meet patient needs.

• A one-hallway configuration is most efficient with regard to physician access to the nursing staff. The physician should have a workstation within that hallway that is also close to his or her clinical team and that does not put him or her in immediate contact with patients as they leave or enter the exam room area.

• Patient privacy should be respected with appropriate barriers such as recessed work stations so conversations cannot be overheard.

• If nurse triaging is being performed, then privacy must be paramount.

Multiple Single-Specialty Physician

The configuration will be different when multiple physicians share one practice area. The functional design of the facility should be centered on maximizing provider efficiency. Certainly, a common waiting room should be configured. As for the production area, the following design guidelines should be considered:

• As with the solo practice, the nursing and front office staff should be within close proximity to promote a seamless flow of communication.

• Nursing triage should be a consideration. This individual should reside between the scheduling and nursing areas but with adequate privacy due to the nature of the conversations that will occur.

• The front office staff should not perform both scheduling and reception functions simultaneously; these should be segregated functions so that patients entering the practice for care and patients calling the practice to schedule appointments each receive prompt, focused customer service.

• The production area should be configured in the traditional H formation. The upper portion of the H should connect front office staff to nursing, with the nursing area being the cross member of the H. The two legs of the H should house the exam rooms. In the upper portion of the H, the waived laboratory testing may also be performed.

• Each physician should have three exam rooms. If midlevels are in the practice, they generally can function efficiently with two exam rooms; if volumes warrant, three rooms might be considered.

• One room should be dedicated as a nurse procedure room. This could be utilized for blood draws, ear lavages, immunizations and injections, and EKGs. This keeps the exam rooms open for use by the providers. This room should be near the exit of the production area, close to the waiting area, so that patients needing early morning blood draws can be easily served.

• If four to six providers are in the facility, then one procedure room should be adequate to accommodate the needs of the practice. This room can be used for a variety of procedures, including dermatology, endoscopies, lacerations, vasectomies, or other procedures that would fit the needs of the practice. If six to ten physicians are in the facility, then two procedure rooms will be needed.

• The scheduling of referrals for specialist services or tests should not be performed in an exam room, as this slows down physician production. It should be performed in a separate room that provides adequate privacy.

• There may be enough physicians to accommodate the cost of providing radiology services. If so, this service should be positioned close to the entry of the physician production area near the waiting room.

These design components work well for primary care. The design components for specialists are unique to each specialty and the ancillary services the specialty provides. For example, urology will need additional restroom facilities as well as procedure area(s). Obstetrics and gynecology will require space for ultrasonography. A general surgeon can function well with two exam rooms and one procedure room. If multiple single-specialty physicians work in the facility, the H design would be appropriate.

One of the most common errors of facility design is establishing a facility in a location that makes the internal operations inefficient and, as a result, costly. Form should follow function. Elevators in the middle of a multistory facility can divide same-practice operations. A one-level oblong facility can accommodate a multi-physician practice but generally will preclude other practices from functioning in the facility. A square building is more efficient for internal operations.

Another consideration is the need for similar service in the same location. For instance, if a musculoskeletal center is present, radiology services should be considered, as well as a casting area. If physical therapy or rehabilitation services are present, they should be located near the musculoskeletal services.

The need for meeting space, an employee lounge, and storage should also be considered. The need for these will depend on a variety of factors, including location of the medical practice in relation to other facilities. If the medical practice location is standalone, then consideration of such add-ons will be necessary.

The placement of support beams, elevators, hallways, common services, and so on can have major financial impact on both physicians and staff. An architect who has experience building medical facilities can be helpful in working through such issues.