Re-engineering Your Practice

Make your office layout serve your needs

One Pennsylvania practice that built a new office found it helped clinicians work better and faster. You can do the same, even if you just remodel.

By Wayne J. Guglielmo
Senior Editor

When you think about improving outpatient care, do you look around at your practice space? You should, because good office design is crucial. "You can't re-engineer optimally in a poorly designed facility," says Roger R. Coleman, a re-engineering consultant based in Pegram, TN.

That doesn't necessarily mean you'll have to start pulling down walls. In fact, before doing anything to change your office's design, it's important to plan how to make your office processes more efficient, cost-effective, and patient-friendly, Coleman and other experts say. Without this conceptual foundation, you might approach physical redesign based on outmoded and wasteful processes.

Plenty of practices do find that it makes sense to alter their physical space as part of re-engineering, however. The renovations might involve nothing more than moving a medical records room to make charts more accessible, or knocking down a wall to allow a patient care team to work together more effectively. But, if an office is cramped for space and its layout obstructs patient flow, you may need to consider more radical alternatives—maybe even design new quarters.

"It's often cheaper to do something new than to remodel," says Wayne Ruga, a Cambridge, MA-based architect specializing in medical office design. "Taking something apart and putting it together successfully is harder than starting from scratch."

Remodeling could also reduce your revenues in the short run. "How do you manage during the transition period if half your office is walled off?" asks internist Charles M. Kilo, a senior fellow at the Boston-based Institute For Healthcare Improvement, which helps doctors re-engineer their practices.

One group practice that chose the ground-up approach is Keystone Health Center in Chambersburg, PA. This 10-physician primary care practice began trying to improve its efficiency several years ago, but was frustrated by the size and layout of its existing space. The lessons learned from the practice's re-engineering experiments were eventually incorporated into the design of a new office building, which was completed in 1998. That facility—a 17,000-square-foot structure whose architecture and interior space are both aesthetically pleasing and highly functional—is a key element in Keystone's continuing success.

A growing practice stifled by poor office space

The practice that was to become Keystone Health Center was founded in 1986 by Joanne Cochran, a nurse and former Catholic nun. Initially a rural clinic for the area's seasonal farm workers, Cochran's shoestring operation grew into a federally qualified health center that cared for a broader patient population, including Medicare and Medicaid recipients.

To staff the expanded program, Cochran persuaded a local GP, George Baker, to fold his practice into Keystone's. Three additional practitioners rounded out the center's team—two physician assistants and Cochran's husband, Bryce, an emergency medicine specialist who volunteered part of his time as a clinician and director of quality assurance.

After moving into an unprepossessing two-story office building near some railroad tracks, the practice expanded further. By the mid-1990s, it employed two physicians full time—FP Edward L. Zuroweste, who had replaced George Baker, and David Hoffman, an osteopathic family practitioner. But with a growing patient load and staff came problems partly attributable to the facility itself. With its low ceilings, dingy lighting, cramped waiting area, and illogically arranged exam rooms, the new space was far from ideal. "That site certainly didn't lend itself easily to teamwork and patient flow," says Roger Coleman, who first visited the Keystone facility in his former role as a consultant with the federal Public Health Service.

The inadequacies of the office space inhibited the staff's early attempts at re-engineering. "You can be efficient if you have the right staff, but physical-design limitations take their toll," says Zuroweste, now the group's medical director. "For example, in the old office, every time I did a Pap smear I had to get up twice, because of how the exam rooms were laid out. That wasted one to two minutes in every exam. By the end of the day, those minutes added up."

Matching office design to re-engineering objectives

Once the decision had been made to build new quarters for the burgeoning practice, Joanne Cochran secured a $2.1 million, low-interest loan from the Office of Community Development of the US Department of Agriculture. The practice paid back nearly $1 million of this with donations from a local hospital and private sources. The architect, Stuart E. Christenson of Noelker and Hull Associates, had extensive discussions with Cochran and other Keystone principals about how the office should look and function.

"We talked a lot about patient flow, for instance," recalls Christenson. "How do you get patients in? What do they see when they enter? Is it easy for them to orient themselves? What happens right before they exit?' Everyone wanted the process of arrival and departure to be as painless as possible."

Edward Zuroweste and Bryce Cochran were especially concerned about the design of the clinical area. Certainly, it needed to accommodate future growth, but neither physician wanted to create a huge, undifferentiated space. The new clinical space, they believed, should be subdivided into smaller areas, or "pods," creating a feeling of intimacy for the patient and encouraging teamwork among providers. This "care team" concept is an essential facet of office re-engineering. ( See "Pick the team, and write the game plan," Feb. 21, 2000).

The office was also designed to please patients and make them feel at home. A patient arriving at Keystone Health Center enters a two-story, light-filled lobby, with a pair of bright-yellow canvas sails hanging from above. To the left is a spacious waiting area, complete with a children's play house in one corner. To the right is a large, curving front desk, divided into stations for reception, cashier, and financial aid. The spaciousness and clearly marked stations provide a stark contrast with the small, poorly lit waiting area in the old offices.

Tighter teamwork, decreased waiting time

In the two years since the new offices opened, Keystone has attracted an ever-broader mix of patients. Today, more than half of the practice's 70,000 patients have private insurance. The practice has grown so rapidly that the number of physicians in the clinic has climbed from six to 10 just this year, with additional staff to support them.

Despite all the new people and the added strain on the facility, the practice runs quite smoothly. Charts are rarely misplaced, and "cycle time"—the length of time the average patient spends in the office—has declined from 45 minutes to about half an hour. Since the physicians still spend about the same amount of time with patients, that reduction has been mostly in waiting time.

This didn't happen all by itself. It resulted from a number of changes initiated by a re-engineering team led by Dave Hoffman. (See "Make the most of your staff," April 24, 2000). Some of these changes could be accomplished in any practice, but most were facilitated by the layout of the new offices.

One key to reducing wait time, for example, was the creation of the new position of "expediter." If a newly arrived patient needs to be seen for an acute problem, the expediter, who works in the reception area, uses her mobile phone to find out whether an exam room is available. (On a typical day, practitioners handle about 100 acute care visits. The center has also recruited a PA for urgent care.) For a nonurgent visit, the patient must wait for one of his own doctor's exam rooms to open up. When it does, a nurse escorts the patient there immediately.

Once in the clinical area, the patient enters one of four clinical pods. Each pod is a 20-foot corridor with three exam rooms on each side. The rooms are brightly colored, with partially frosted exterior windows. The interior design also emphasizes efficiency: Equipment and supplies that clinicians are likely to need during a visit are placed within easy reach. "It's the kind of design that can save you minutes on each visit," says Zuroweste.

Each of the two clinical teams that take up a pod uses a bank of three rooms. Currently, a clinical team consists of a practitioner and at least one nurse. A third nurse alternates between teams, depending upon patient volume.

At the head of the corridor is a pair of adjoining nurses' stations, each with its own computer. The relatively short distance from the nurses' station to the end of the corridor, says Coleman, cuts down on "sneaker time." It's a small benefit, he notes, but cumulatively, it saves a significant amount of time.

The proximity of the nursing station to the clinical action also gives nurses a greater role during the patient visit. By the time a patient is escorted to an exam room, a nurse has already scanned his chart for overdue exams, needed immunizations, and the like, and has affixed a note to the chart for the doctor. After a routine visit, nurses update the chart, fill out the required forms, schedule tests or lab work, and set up the next appointment.

Using nurses rather than support staff to schedule follow-up appointments has worked out especially well, says Zuroweste: "They really understand the schedule and how long different kinds of visits take. They're a lot more savvy than the nonclinical staff."

Nurses also play a central role in patient education. They go over diet instructions with diabetic patients, for instance, or escort patients to the prenatal counselor or the HIV/AIDS coordinator in the practice.

If no follow-up is required, a patient exits the pod with his chart and a bill in hand. Boldly colored linoleum flooring guides him directly to the cashier.

Chart flow: well organized but cumbersome

Directly behind the front desk is the central administrative area, which staffers refer to as the "war room." Here, in separated areas, triage nurses field incoming calls, schedulers book appointments, and accounts receivable clerks chase late payments. The war room is also where Keystone stores patient charts in a series of seven-foot carousel files. The files make a tight space seem even tighter. Despite this, having patient charts centrally located is a decided plus, say staffers.

Typically, the medical records department prepares for the next day's schedule by pulling charts and distributing them to the care teams. When a patient checks in, the team nurse places his chart in the room where he'll be seen. At the end of the visit, the physician or PA updates the chart, and the patient returns his chart to the cashier station, where it's collected by a record clerk and returned to the carousel files. If a test must be ordered or a referral authorized, the chart remains in the pod until the nurse makes the necessary calls. After that, the chart is picked up when the record clerks make their hourly sweeps of the clinical areas.

Routine lab, radiology, and other reports are received each day via a courier system. The records department sorts the reports and drops them off at the nursing stations for the doctors to look at. The signed reports are later retrieved and placed in the chart folder.

The procedure is somewhat different for stat reports. Typically, the hospital faxes results directly to Keystone's lab, located between two of the pods. Nurses pick up the faxed reports, hand them to practitioners for their signature, and then attach the faxes to patients' records. Record clerks replace the faxed reports with the originals when they come in.

Chart updating and tracking at Keystone is well organized but cumbersome. "Pushing charts all around the way we do is ridiculous," says Dave Hoffman. He, like others at Keystone, looks forward to the day the center will switch to electronic medical records. The re-engineering team is already discussing how to redesign office processes—as well as the existing physical space—for the advent of EMRs.

The team has also discussed ways to improve the front desk design. By creating a rigid separation between staff and patients, practice leader says, the barrier-like structure conveys the wrong message. A more fluid design would permit patients to enter and exit at will.

Of course, no design—not even one as well-thought-out as Keystone's—can accommodate all the changes taking place in health care. That's why experts stress the importance of flexible design for primary care practices. "The question is, how do you build space flexible enough to allow you to adapt to whatever innovations come down the road?" asks internist Charles Kilo of the Institute for Healthcare Improvement.

Few practices accomplish that goal, says Kilo. For example, if Keystone wanted to hold group visits for chronic-disease or elderly patients, its current design would prove a hindrance. "There's no clinical space large enough," Coleman agrees. "Offices are trapped by their architecture."

Office redesign requires a conceptual approach

Whether you're planning to remodel your office or build a new one, you should consider several factors before you sit down with the architect.

First, decide how large your care teams should be, who should be on them, and how the members should work together. For Keystone, the right team turned out to be a physician or PA and one or two nurses. Knowing much of this beforehand helped Keystone's leaders make essential design decisions regarding pod size, number of exam rooms, nursing-station layout, and so forth. Practices that have a different vision of clinical care will make different design decisions.

Second, look at your patient flow and the particularities of your practice. An oncology practice in Providence, RI, for instance, designed open spaces for patients receiving chemotherapy. The idea is to encourage conversation, thereby breaking down the feeling of isolation. A primary care practice like Keystone, in contrast, is based on one-to-one communication between doctors and patients.

Third, keep an eye to the future. Construct the physical space so it can be easily altered to accommodate group visits or to reduce the amount of space devoted to charts when you acquire an EMR system. Flexibility may be the most difficult design element, as the Keystone example demonstrates. But without the means of re- configuring an existing design—by moving walls to accommodate a re-engineered patient flow, for example—practices can change office processes to only a limited extent.

Finally, say experts, pay attention to costs, but don't make a tight budget the scapegoat for a poor design. "Any skillful designer can do a beautiful piece of work, whether you give him $10 or $100 a square foot," says architect Wayne Ruga. "I have no sympathy when people say we had to settle for a poor environment because we didn't have enough money."

More crucial than a big budget, says Ruga, is the set of values prompting the new design. Is the new setup efficient, and does it also convey a respect for human dignity?

In the case of Keystone Health Center, most observers would agree, the answer is Yes on both counts.

Next up: making sure you have access to patient charts when you need them.

 

Ken Terry, ed. Wayne Guglielmo. Make your office layout serve your needs. Medical Economics 2000;12:60.