How to Make Ambulatory Care Centers More Adaptable

Six Ways to Prepare for the Next Pandemic by Reconsidering Healthcare Design Guidelines

May 26, 2020

Senior Associate, NBBJ

bitarnoelia

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

Editor’s Note: This post was co-authored by Noelia Bitar and Paula Buick.

 

The number of outpatient centers has increased dramatically in recent years, but as scheduled appointments were canceled during the coronavirus, this valuable real estate stood empty. Because ambulatory centers already have basic healthcare infrastructure in place, they potentially could flex to accommodate an inpatient surge; however, many of these facilities were designed to meet only the minimum requirements of current codes — like the FGI Guidelines, which establishes national standards for the design and construction of healthcare facilities — and as a result their ability to be adapted for inpatient care is limited.

As we think about building new ambulatory care centers, a few design considerations, above and beyond code minimums, could make it easier for these facilities to flex to meet future inpatient surges or post-acute care needs. Given funding constraints, it may be challenging to incorporate all of these features into every ambulatory care center; however, these are some of the options a health system might consider:

1. Build public spaces that allow for easy conversions. If utilized during a surge event, ambulatory care centers would likely transition from opening only during a set number of hours each day to a 24/7 service, which, because inpatient care requires more staff than outpatient, would require an overall increase in staff on all shifts. This increase would require additional support areas, which will impact the design of public spaces. These spaces should be designed so lobbies can be converted for triage (screening, testing, queuing, etc.) and patient waiting areas converted into “team work areas” where care team stations, staff amenities (lockers, lounges) and clinical support services can be located outside of patient areas that might be required to be isolated. The code currently requires waiting areas to have a ratio of 1.5 to 2 chairs per patient care room, but it does not specify a square footage per chair; we find that 25 square feet per chair is a good standard for providing additional future space flexibility in waiting areas.

2. Design exam rooms to flex beyond outpatient care needs. The minimum clear floor area required for patient exam rooms per the guidelines is 80sf, but as we design for future flexibility, we could see a shift to allow for stretchers to be used in these rooms. Taking into account the appropriate clearances that might be required, 120 square feet is a more appropriate minimum, and sometimes 140 square feet for multidisciplinary-based team care.

Medical gases such as oxygen and vacuum could be included in at least some exam rooms, even though the code does not require any medical gases in a standard exam room. The addition of medical gases in general ambulatory centers will allow for these rooms to flex when needed.

Because telehealth is important not only for expanding access to care but also for helping to reduce exposure to contagion for both patients and staff, it would be beneficial to integrate technology and design that supports telehealth or teleconsults into more exam rooms. While the outpatient guidelines offer dedicated spaces where telemedicine could take place, such as a bay, cubicle or room, including it in every exam room would provide additional support. Consider elements such as:

  • Monitors with fixed cameras or mobile carts for telehealth and remote consults to be able to remotely view and communicate with patients
  • Communication tools, including “nurse-call” that is voice-activated (the current code does not require nurse call devices in exam rooms)
  • Television for patient distraction and education

Larger 4′ (or 48″) door openings could be the new norm for the exam room and all patient areas — even though door openings serving occupiable spaces are usually a minimum clear width of 34″, or 41.5″ where stretchers are used, and 4′-door openings are typically only required in the path of travel to public areas and in areas where care will be provided for patients of size. Using sliding doors or double-leafed doors could accommodate a wider opening without impacting the design of the room.

Even though an exam room, by code, requires privacy for patient consultation, integrating a transparent material like a narrow light or half window with integral blinds would allow it to flex into an observation room, which by code requires patient visibility. Sliding glass doors with a translucent film could be used to maintain privacy while providing light into the corridors during normal exam-room use, but the film could easily be removed and allow for transparent glass, if the room needed to flex for observation.

3. Plan for an isolation zone within outpatient care areas. An entire floor or section of an ambulatory care floor could be designed to become a negative pressure area. Rooms would need to identified for transforming into donning/doffing PPEs, and with a one-way entry and exit flow.

Similarly, while Airborne Infection Isolation (AII) exam rooms are only required in specific programmatic ambulatory needs, having the option to accommodate a patient who has screened positive for an airborne infection may be advantageous in the surge response plan. A minimum number of AII exam rooms could be required, along with an adjacent room or space to serve as an ante room or vestibule. And don’t forget that patient isolation can function at multiple scales.

4. Expand corridor widths to allow multiple flows. Although outpatient guidelines only require 6′ corridors in areas where there is use for stretcher transport, if corridor widths were required to be a minimum of 6′ throughout, they could accommodate stretchers and other circulation needs, and support PPE carts outside rooms, EVS cart parking, patient transportation etc.

5. Choose the soiled workroom over the soiled holding room. Most outpatient general facilities only require soiled holding rooms in exam areas, as they are only used for temporary storage of soiled materials and supplies — as opposed to more intensive soiled workrooms, which include additional plumbing and space in which staff can work. However, choosing to include the soiled workroom in outpatient settings will also allow for cleaning or disposal of soiled items with the multiple sinks required by code for inpatient care.

6. Add redundancy in infrastructure. Including additional electrical power in public areas like waiting rooms and exam rooms makes it possible to support additional equipment loads such as physiological monitoring, mobile diagnostic equipment, emergency power and more. Likewise, HVAC systems ideally would be flexible enough to accommodate 24×7 patient care, additional cooling for increased staffing, thermostats in each exam room or the modest increase in air changes per hour — from 4 to 6 — required by code for inpatient settings. Most general ambulatory centers like medical office buildings do not require these types of redundancy per code requirements.

Many of these features will entail additional costs. However, there are also significant costs associated with leaving an ambulatory care space idle because it is unable to meet unexpected care needs like the Covid-19 pandemic. Some additional upfront investment may be necessary but doing so will ensure that these centers will be ready to flex when the next emergency arises.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Sean Airhart.

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Getting Hospitals Back on Track: Safely Bringing Healthcare Back Online

How to Prepare Our Hospitals to Balance COVID and Non-COVID Care

May 21, 2020

Healthcare Partner, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Ryan Hullinger and Sarah Markovitz.

 

Since the middle of March, nearly all elective surgeries and medical procedures in America were postponed to create capacity for the first wave of Covid-19 patients. While the curve has started to flatten and many facilities are reactivating their procedural platforms, there is still hesitation in patients seeking in-person care for fear of inadvertently exposing themselves to the virus. As a result, many patients with both chronic and acute conditions are putting off necessary health maintenance and avoiding trips to the hospital.

For the healthcare industry, this is devastating both in terms of its impact on patient care and its bottom lines. Hospitals — especially non-profit hospitals — historically operate on extremely narrow financial margins. With so many departments sidelined, the average American hospital has seen an estimated average drop in operating revenue of 40 – 45%, resulting in significant furloughs. These actions take a huge emotional toll on staff, many of whom were bracing for battle only a month ago and are now suddenly without a job.

America can’t afford to continue putting its wider healthcare system on pause in the likely event of another patient surge in the summer or fall. So what solutions could help keep appointments and procedures on track? And how can we ensure that they are performed in a safe manner?

All entrances, lobbies and screening processes should look calm and well-organized to assure patients that the facility is in control of the situation and safety is the number one staff priority.

There are many design changes that can make this happen and many of them begin before patients set foot on hospital grounds. Hospitals should use their websites to present clear communications with patients so they are aware of the safety precautions and instructions for their arrival.

Inside the hospitals, there needs to be legible signage that communicates cleaning and disinfecting processes for the facility. For example, many hospitals have existing digital signage outside of rooms that previously communicated room occupancy. This can be repurposed to communicate cleaning frequency and efficacy. This can be as simple as something like “This room was cleaned three minutes ago and is ready for use.”

Thoughtfully planned wayfinding will be equally important. These need to demarcate separate pathways for those with and without Covid-19 symptoms entering the site, covering the patient journey from the parking to the entrance to the treatment areas. Wayfinding solutions could use unique colors and shapes – such as the color pink or a triangle shape – to help messages stand out.

Planning hospital flow for optimal safety

Accommodating coronavirus and non-coronavirus patients in the same hospital requires thoughtfully planned and clearly delineated processing and treatment zones. The Centers for Medicare & Medicaid Services recommends establishing distinct zones for each group. In the coronavirus care areas, symptomatic patients will be identified, screened and receive appropriate medical guidance and contract tracing efforts. Where possible, these areas should be physically separate from other hospital services — this could be a different building, a dedicated room/floor with its own entrance, or pop-up tents adjacent to the hospital.

For patients with Covid-19 who come for treatment of other issues and conditions, a bespoke multidisciplinary clinic can be set up to address their needs. For patients who have yet to be screened, administrators can work together to plan uni-directional flows throughout hospitals so those coming in and going out don’t cross paths with one another.

This will also require consideration for features like elevators to ensure they don’t become contamination zones — potentially by having designated staff operate them, reducing the number of persons allowed in at any given time, and identifying separate elevators for coronavirus and non-coronavirus patients.

Rethinking the waiting room

Balancing care for coronavirus and non-coronavirus patients in parallel may require rethinking the traditional waiting room entirely. Hospitals are designing new patient experience systems to alleviate patients’ anxiety by limiting the amount of time in the hospital outside of direct appointments and treatment.

After being screened for Covid-19 at a triage tent, patients can wait outside the hospital until they receive a text that their doctor is ready to see them, at which point they are taken straight into a treatment room to promptly be seen by their provider. By using mobile communication tools, these hospitals are decentralizing and streamlining the waiting room experience.

For the majority of Americans who access hospitals with their own vehicle, cars could become the new waiting room. For those living in more urban settings, hospitals can consider converting larger and more spacious rooms like cafeterias and conference rooms into waiting areas. This would allow for greater distance between patients waiting to be seen. Reconfiguring furniture for appropriate spacing, leaving signs on chairs and tables after they’ve been cleaned, and using markers to establish appropriate distancing for any lines are all immediately actionable solutions.

All of these considerations will change as PPE supplies, Covid-19 screening, antibody testing, and tracing programs continue to evolve. By closely aligning thoughtful and innovative hospital programming and operations with solutions that project a sense of safety and care, we can start to reconfigure our hospitals and healthcare facilities to operate within this new reality.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Benjamin Benschneider.

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Fear Factor

Seven Choices for Work Environments that Underscore the Need to Respond, Not React

May 20, 2020

Partner, NBBJ

@ryanjmullenix

COVID-19 illuminates the world to many pitfalls in current workplace design. Issues of density, location and balance have been laid wide open for all to attack. That’s a good thing. But in the ensuing conversation, are emerging ideas actually more regressive?

During a time of unknown, humans desperately want answers. When we’re inundated with information and anxious about the world around us, we often look for quick solutions. We also miss long-standing cues, touting reactions as fresh ideas instead of acknowledging them as changes that should have already occurred (look no further than the 35-year notion of biophilia). But more dangerously, we can generate solutions without considering what makes us who we are: human. As this unfortunate crisis fuels a long-needed conversation about where and how work is done, I’m most wary of ideas that celebrate the expected to the detriment of those doing their jobs.

Below are predictions made from a reactionary mindset, coupled with realities that have been in front of businesses for some time. These positions are countered by responses that, instead of holding our working society back, seek to pull it toward lasting results.

Reaction: We will need to de-densify
Reality: Employees have already made this decision

Yes, fewer people with greater distance in-between means less likelihood of spreading or contracting disease. But we’ve known the implications of density on holistic human health since the industrial revolution. It’s no coincidence that as the number of square feet per person has decreased in an office, so has floor efficiency as more people work remotely due to these conditions. For the last 15+ years, technology has enabled workers to vote with their feet to create “preferred density.”

There’s a strong desire to solve problems with concrete measures like physical space metrics and basic division (overall square feet divided by total population). However, this challenge seems better suited for organizational strategies that align work modes with the proper environments to support them. It’s beyond simply offering the chance to work from home – it also means not designing ubiquitous spaces that try to be everything to everyone, an aspect of the “open office” that many despise. This attitude will allow companies to reduce the number of people in a space at one time (less density) while increasing the number of employees a space serves (more use). The resulting choreography should increase job satisfaction while reducing congestion on the road or on public transit, an outcome our planet and nervous systems would greatly appreciate.

Reaction: We will need a six foot physical boundary around us
Reality: People will return to the office to overcome barriers, not to create them

In addition to reducing density, establishing physical separation between people is being advocated through the return of the protective cubicle (sneeze guard included). As much as my engineering mind loves games like Tetris, repeatable system layouts that drive how people do their work are rarely the right place to start. And what are the correct dimensions? Testing is showing just how variable the range of a virus can be.

It’s not necessarily a coincidence that when the movie Office Space appeared, cubicles nearly disappeared. Cubicles are isolating and demoralizing, they block light and view, and most use porous acoustic material (aka virus breeding grounds). Why come to an office for that? I hope that before putting this solution into action, we fully understand the risk of adding these anachronisms to our offices – and then landfills – again.

Reaction: We can fuse social interaction and isolation into one space
Reality: It’s impossible to go against our hard-wired brains

There are suggestions that we should build workplaces that enable us to be together and yet apart. Is the office of the future the awkward middle school dance of my past? Or will it be a game of tag, where we can’t help but try to guess who’s “it” – an outcome that soberly could lead to inadvertent discrimination.

We all appreciate the importance of engaging others in our personal and professional lives, especially now. With that comes the beautifully organic, somewhat unpredictable means of interaction. As a result, there will always be pinch points. Visit any grocery store now to feel this in full effect. At the height of this crisis, even strangers are challenged to respect mandated personal space. Although spatial configuration, RFID mapping, and visual cues may offer a quick but uncomfortable solution, advanced health screening and progressive quarantine protocols should provide greater confidence in our interactions. This trust-based attribute is important to team risk-taking and creativity. It’s also more inclusive for those with impairments.

Reaction: We must limit our sharing of technology, and potentially, space
Reality: Nobody wanted to use someone else’s keyboard anyway

Reducing the transfer of communicable disease through what we touch is important, but let’s be honest, sharing work supplies is almost as bad as getting the warm chair in a conference room. Although I hope the share economy continues in many forms, “hot-desking” has forced a bigger conversation around blurring personal preferences with professional support (if we ever want that concept to return, we should rethink the name).

The opportunity in this moment is to better discern the significant distinction between individual and communal uses. Such insight will be crucial to reimagining post-COVID buildings that can still become 24-hour shared resources. Psychology and urban design provide much-needed expertise in identifying the spaces and places that humans will accept as co-habitable.

Reaction: We must upgrade our air filtration systems
Reality: We’ve been breathing bad air for some time. Improving health goes beyond filtration.

Clean air is something we’ve struggled to achieve in the office for 40 years. Our fascination with sealing buildings entirely in the 1980s left us with a false sense of domination.  When our environments became artificial – lighting, heating, cooling, etc. – our minds felt we were controlling nature while our bodies knew otherwise. This arrogance blinded us from the reality that CO2 buildup in our conference rooms was impacting our thinking.

Instead of only upgrading filtration, rethink the entire mechanical approach. Thermal mass, radiant systems, and self-shading require less air to be conditioned and then circulated. Where possible, increased natural air changes are obviously ideal. Don’t forget to address exhausted air; what we spew out of our buildings not only impacts global warming but the health of our neighbors next door.

Reaction: We require chemicals to achieve healthy workplaces
Reality: Wait, more chemicals in our environments? Let’s focus on awareness.

Understandable anxiety around the unseen prompts us to default to what we know works. It also reveals the danger of environments being curative, not preventative. Yes, chemicals can eliminate viruses, but let’s not lose sight of the fact we had just committed to getting hazards out of our spaces.

While sanitation is important, much of a healthy environment is derived from individual attentiveness and choice. Practitioner insights and raised awareness around personal hygiene, general cleanliness, and bathroom etiquette will hopefully keep us from having to take an untested blanket approach. Nature (surprise!) may also have an answer. We continue to learn more about daylight and temperature as allies in fighting viruses. We can also proactively bolster immune systems through universally-accessible pinenes like cedar and rosemary, both which smell better than disinfectant.

Reaction: We won’t need offices anymore
Reality: What is an “office” anyway?

This definition depends on the work you do and how you do it. Sure, technology has increased the number of tasks we can do remotely. But it hasn’t satisfied our desire for social interaction, or the heightened sentience and better ideas that can come from it. It also hasn’t changed the fact that physical space helps reinforce the tangible ethos and culture of an organization. Without these relationships, we risk becoming teams of task-based contractors searching for identity and connection to mission.

We continue to have a dualistic mindset of work happening in either an office or at home, but as we’ve known for years, work for some people can happen everywhere. How it’s done best, however, is dependent on you, the work you’re doing, and the experience you seek. Today I’m less intrigued about fewer days in the office and more interested in fewer hours in one place, office or not. We can all benefit from mapping out what makes our individual workdays rewarding.

In light of constantly emerging and often-changing information, responding to causes versus reacting to symptoms is essential. It’s a challenging feat – we as humans will never be free of compulsive reactions because we want the surety that quick answers seem to offer. Unfortunately, though, those answers usually lie within our own spheres of influence. Broader exposure to science, history, and design thinking is critical to ensuring meaningful progress. Don’t rush ahead because you’re afraid of being left behind. Use this pause to interpret that fear, and then respond with your way of working. Exemplify awareness… your fellow humans need it.

 

How are you and your organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

Banner image courtesy Sean Airhart.

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