Practice makeover: Designing a modern medical office

When Gary LeRoy, MD, FAAFP, signed on as medical director of a community health center in Dayton, Ohio, it consisted of a single physician and dentist, a nurse practitioner and a handful of other employees housed in a 5,000-square-foot former grocery store.

Today, the center-now known as the East Dayton Community Health Center-bears little resemblance to the facility LeRoy joined 16 years ago, despite being in the same location. For starters, it’s doubled its size by expanding into formerly vacant space in the rear of the building. It now employs two physicians, two nurse practitioners, and nine staff members.

Equally important, the building’s retail-like ambiance has been replaced by a welcoming environment, due in part to the abundant natural lighting provided by skylights. The waiting room has plenty of comfortable furniture for adults and a play area for children.

In addition, LeRoy says, the center improved its efficiency by changing the way patients flow through the building, and created work pods where physicians and support staff can talk without being overheard by patients.

“We basically redesigned the building from the ground up,” recalls LeRoy, now a board member of the American Academy of Family Physicians. “Everybody drew up their wish list of what they wanted to see in the facility. Then we sat with the architect and said, ‘how can we realistically create the components everyone is asking for?’”

As a result of its makeover and expansion, East Dayton now serves about 15,000 patients annually and has been designated a Federally Qualified Health Center. It also hosts community classes on health and stress reduction. “We decided that since we’re a part of the community we should provide services of use to the community,” LeRoy explains.

While East Dayton’s overhaul may have been more extreme than most, it was far from alone in undertaking it. In a 2016 survey by the Medical Group Management Association (MGMA), just over half of respondents said they either remodeled, added space, moved, or made some other change to their practice space in the past two years.

Ken Hertz, FACMPE, principal consultant with the MGMA, says those numbers don’t come as a surprise. “Given the rapidly changing healthcare landscape, practices and physicians are coming to see it’s vital that they continually reinvest in the business by updating their space, changing the aesthetics, introducing new technology and so forth,” Hertz says.

Reasons for practice makeovers

So what are some of the tell-tale signs that a practice may need a makeover?  They fall into three broad categories, experts say: space, appearance, and productivity. Of these, space-or the lack of it-is usually the most obvious, since it’s readily apparent when a practice can no longer accommodate the needs of its patients and providers.

David Zetter, CHBC, founder and lead consultant of Zetter HealthCare in Mechanicsburg, Penn., cites the example of a client, an urgent care center in an Orlando, Fla. strip mall just outside Disney World.

“Every time I’ve walked in there, the place is packed,” Zetter says. “They’ve got patients standing outside or sitting in their car waiting to be called because there isn’t enough room in the reception area.”

Fortunately, Zetter adds, an adjoining storefront came available that the client plans to buy, even though it’s more room than the center currently requires. “There’s a perfect example where somebody realized, ‘I’ve got to do something about this situation,’ and he’s going to spend a lot of money on it to do it right. But he’s confident, given how busy he is, that he’ll get a return on his investment.”

The need to freshen its appearance, especially in the patient waiting area, is another frequent catalyst of practice makeovers. That’s especially the case, experts note, given that the waiting area is where patients form their first impression of a practice. Worn-out carpeting, lack of comfortable seating, outmoded decor, absence of Wi-Fi, and use of fluorescent lighting are all indicators that some serious remodeling is in order for that space-and likely the rest of the practice as well.

“Put yourself in the patient’s shoes”

Sometimes doctors, even if they own the practice, may not be aware of problems with the waiting room simply because they rarely see it. That’s because in many practices clinicians and staff members use a separate entrance that takes them directly into the work area.

The way to overcome that disconnect, Zetter advises, is to “put yourself in the patient’s shoes. Walk into your reception area, sit in the chairs for a little while and ask yourself, ‘is this where I would want to spend time waiting to see the doctor?’”

Hertz says that in some client practices he holds weekend strategic planning sessions in the waiting room. “I make the docs spend a day or two where their patients sit every day, and I see them walking around going, ‘holy cow,’” he says. “Usually on Monday morning they’re saying to the practice administrator, ‘please get us some new furniture and have the walls painted as soon as possible.’”

Sometimes the signs that changes are needed show up in a practice’s processes and workflow. “If a practice starts seeing its doctors consistently running behind schedule, or patients aren’t ready for them to see in the exam room, that’s a pretty clear indicator that something’s going on,” says Larry Brooks, AIA, principal of Practice Flow Solutions, a medical space planning and consulting firm in Roswell, Ga. “A lot of times it stems from just not having the space to check people in or do a pre-exam workup.”

Identifying needed changes

Once a practice has decided it needs a makeover, the next step is deciding on the specific changes it wants to make. For a small practice, the process is similar to remodeling a home, Hertz says: the physician-owner and office manager should inspect the practice’s rooms, equipment, and furnishings and make a list of everything they want to see fixed, changed, or disposed of.

For larger practices, experts recommend convening clinicians and staff members by department and soliciting their input. “Ask them, ‘if you could have a new space, what would it look like? What are the things that aren’t working now and what changes would make our patient care better and help support the work that you do?’” Hertz says.

Patient suggestions for improvements can also be helpful, he adds. Some practices he’s worked with survey their patients via phone, e-mail, or regular mail, while others will invite patients to come in person during an evening or weekend to make recommendations.

Regardless of its size, often a practice can get useful ideas just from looking around to see what others are doing, Hertz says. “If the administrator or docs or staff have been to offices they think are fabulous, or have seen pictures in magazines or newspapers, bring them in, put them in a book and keep them as a resource,” he advises.

Advice and suggestions from other practices who’ve undergone the process is also helpful. “Ask colleagues, when they got through with their makeover what were the things where they went, ‘Oh my God, how could I have forgotten about this?’”

While practices will differ in the look they want to achieve depending on their financial constraints and the tastes and desires of owners and staff, experts agree that the goal is to create an ambiance that is up-to-date, comfortable, and inviting. “Nowadays, nobody wants to be in a sterile office environment,” Zetter notes.

Lighting, wall colors, and fixtures are important parts of a makeover, so Zetter advises practices to consult interior design specialists on how to use these to create the look and feel the practice wants.

Reception area amenities and furnishings are similarly crucial in creating a hospitable, patient-friendly atmosphere. For Brooks, the most important element of a good waiting room is having plenty of chairs with armrests, particularly if the practice serves a large number of elderly patients.

“A lot of times you’ll see practices with nice couches and sofas, but it’s hard for an elderly person with back or knee problems to get out of those,” he notes. “Individual chairs with arms allow them to get up and sit down much easier.”

Other conveniences practices should consider include coffee, snacks, carrels for patients to work in while waiting, charging stations for electronic devices, and Wi-Fi. “Even the grandmas and grandpas are texting and e-mailing with their phones these days, so Wi-Fi has almost become a given,” Brooks says.

Experts note that updating a practice’s appearance need not be expensive. Sometimes, Hertz says, putting down new flooring and carpeting, repainting walls, and re-covering furniture can achieve the desired look without spending a great deal of money. He recalls working with a practice in need of a new paint job but whose physician-owner didn’t want to spend money for professional painters.

“I pulled together some of their staff and we got painting equipment and brought in pizza and soda and painted the place ourselves, and it looked like new,” he says.

Improving productivity

When it comes to redesigning for improved productivity, experts say practices should focus on eliminating bottlenecks that slow the movement of patients through the office. A common one, according to Brooks, occurs when receptionists are required to both field phone calls and check in patients, causing backups in the latter process. Another is when doctors have to leave the exam room to get something they need or communicate with another provider or staff person, thereby extending the patient visit.

That issue ties into what Fields calls the “number-one time waster” in a medical practice: walking. During his three decades of time studies, he says, “the amount of time doctors spend walking between exam rooms, or for tasks like taking a chart to a ready rack or finding a staff member to verbally deliver orders is mind-boggling, when you consider the doctor is the highest-paid member of the practice.”

Brooks says practices can alleviate this problem during remodels by “podding” exam rooms-putting them across the corridor from each other rather than stringing them out along a corridor, which causes doctors to have to walk further between them.

Another helpful technique is to place mini work stations near the doctors’ examining rooms. “That way if they want to make some notes or take a phone call between patients they can do it close to their rooms, versus going to their ­office, which might be far away,” he says.

An important issue practices need to consider when planning a makeover is the exam room: designing it to ensure that doctors can maintain patient eye contact while typing in their EHR, and if possible show the patient the information they are entering. “You want to avoid the situation where the patient is talking to the back of the doctor’s head while they’re typing on the other side of the room,” LeRoy says.

Hertz says some practices initially addressed this problem by mounting computer monitors on the walls of exam rooms, thereby allowing doctors to face patients and patients to see what the doctor is typing.

In recent years practices have begun using laptop computers and tablets, which afford much greater flexibility than desktop computers. Some are also providing mobile tables, enabling doctors to wheel the EHR from room to room and position it to
accommodate the patient.     

An additional exam room feature to keep in mind, Brooks says, is standardization. Designing and supplying them identically means providers don’t have to spend time looking for items they need. “A doctor or staff member should be able to walk into any room, close their eyes and know where everything is, even to the point where they know each drawer has certain things in it,” he says.

Executing the project

With a practice’s makeover wish list in hand, it’s time to execute the project. If it involves reconfiguring or adding space, an architect is essential. The best way to find one, experts agree, is through old-fashioned word-of-mouth and networking.

“This is where you reach out to colleagues in your community who’ve redesigned their space and ask who they used for the project and what their experience was,” Hertz says. After developing a list of candidates, check references and, if possible, visit other practices to view a candidate’s work first-hand.

Once the architect is on board, he or she will price out the practice’s wish list and work with administrators and doctors to determine which of them are financially and/or technically feasible. The architect will also draw up the plans and assemble the other members of the project team, such as the construction contractor and interior designer. 

For a makeover that’s only cosmetic-a new paint job or flooring, for example-an interior designer alone will usually suffice. While administrators and/or doctors sometimes want to select colors and fabrics themselves, Hertz advises leaving these decisions to design specialists.

“Someone with experience in this area will have a better understanding of the colors, materials and textures needed for the look and feel the practice wants to achieve  for its space,” he says. 

When work gets underway, practices face the challenge of minimizing any disruption and inconvenience to employees and patients while continuing to function. Here, strategies differ depending on the scope of work involved. If the practice is adding space, Brooks says, the typical approach is to build the new space first and move the practice’s operations into it while work is being done on the existing space.

If the practice is just renovating or reconfiguring its existing space, Zetter says, the choices are to work on one section of the office at a time, or have the work done during evenings and weekends.

The latter is usually the best approach when it comes to the waiting room, Brooks says. “I’ve seen a lot of groups close early on Friday and give the contractors over the weekend to do the stuff they just couldn’t get to with patients in the office. That seems to work pretty well,” he says.

Regardless of how the work is scheduled, it’s vital to inform patients and staff about what the practice is doing, why, and how long it’s expected to take. Zetter advises posting floor plans and artist’s renderings in the waiting room and around the practice so everyone can see what the result of the work will be.

“When you’re letting patients and staff know what’s going on, it gets everyone kind of hyped up and creates an atmosphere of excitement,” he says. “That makes noise and disruption easier to take.”