Ambulatory Care

John Kelly, Frank Zilm, D.Arch, FAIA
.
Ambulatory care includes any care and treatment where patients stay in a healthcare setting is less than 24 hours. The one exception to this definition is an emergency visit that may result in an admission to a hospital. Ambulatory care, also referred to as outpatient care, has expereinced a more significant growth in the US that any other area of health care. The Center for Disease Control(CDC) surveys between 1997 and 2007 indicates a 25 percent growth in visits, from slightly under 1 billion to 1.2 billion. Use rates vary significantly by age. On average, newborns have 8.9 visits per year. This rates drops to a low of 2.4 in early teen years (5-14) and then starts to rise with age, ending again at 8.5 visits annually for 75 + population[1].
.
The factors contributing to this growth will continue in the future. Ambulatory care is less costly than patient hospitalization. Development of minimally invasive proceduresand local anesthetics make more treatments safe and efficient in outpatient settings. More and more diagnostic examinations are performed as outpatients. In many cases ambulatory facilities can be constructed under less stringent building codes, resulting in lower costs. Creation of off-site outpatient centers have been created by hospitals to allow for expansion of acute care on constrained sites.
CDC data
.
With the exception of serious trauma and other emergencies, most patient care is typically initiated in an outpatient setting. There are four typical portals:

  • Primary care providervisits – a primary care provider includes family practice, internal medine, obstetrics, pediatrics and other providers that treat a broad range of medical conditions. Primary care providers are frequently referred to as the “gate keepers” of the healthcare system due to their role in referring patients to specialists and their use of diagnostic services.
  • Specialty care providervisits – There are a wide range of surgical and medical specialists. These physicians focus their skills in specific areas of health, such as cardiology, endocrinology, oncology (cancer), general surgery, orthopedics, neurosurgery, neonatology, and other areas. Depending upon the specialty and on the specific patient condition, a specialist may provide some level of primary care in addition to their unique area of focus.
  • Emergency/urgent carethis will be exlored in more detail later. Emergency care has expereinced a growth of two percent annually since the mid 1980’s. Much of the care provided in EDs classify as primary care. The unique core of emergency care is the ability to manage high risk patients.
  • Allied Health Professionalvisits – a significnat volume of outpatient care is provided by non-physician professionals. This includes physical therapy, audiology, nutrician, and genetic consuling.
The largest volume of ambulatory care is in a primary care office setting, accounting for almost half of all visits.

Ambulatory Care 2
.
Four drivers of ambulatory care design include:
  • Functional efficiency – including access, movements and location of services.
  • Flexibility/Sustainability – designing facilities for long term viability by allowing for change and expansion.
  • “Healing” environments – designing environments to support the physical and emotional needs of patients, family, and staff.
  • Costs – providing both low first dollar costs and efficient operational costs
A fundamental of ambulatory care is the movement of patients to, and through, the care environments. This contrasts with inpatient hospital care, where much of the care is focused around the patient room., with necessary transport provided by hospital staff The development of a functional design must begin with site access and vehicular circulation.

Ambulatory Care 3
.
Provision for disabled patients, travel distances, and efficient drop-off and pick-up spaces are critical considerations. The separate patient from staff parking to assure that parking spaces proximate to the building are not occupied by staff arriving early in the morning. The number of parking spaces should be based on estimates of peak staffing and patient flow. A general “rules of thumb” is four parking spaces per physician, nurse practitioner and other professionals seeing patients, or 5 – 5.5 spaces per DGSF. If the facility includes imaging or other diagnostic and treatment services (such as physical therapy), additional parking allotments will be required for staff and patient demand.

Sizing the building typically seeks a balance between specific program needs, establishing common spaces for flexibility, and the location of services to allow for expansion and adaptation of new functions over time. Sizing of primary and specialty care clinics centers on estimating the number of exam rooms. Once the exam room count is established, the other direct care and support spaces are added to get an estimate of the departmental gross square footage(DGSF). We will discuss methods for estimating room requirements later in this course. A general pattern is to assume three exam rooms per primary care provider and two exam rooms for specialty providers. The difference in the ratio is a reflection of the longer patient time typically seen in specialty practices. The total departmental gross square feet for all spaces in an office area typically fall in the range of 1,000 to 1,500 departmental gross square feet per provider.

Flexibility/adaptability

Given the dramatic growth and change in ambulatory care, a primary design concern has become how to accommodate this change over time. Long term flexibility can be achieved through a combination of initial programming decisions and effective design concepts. One programming technique is to define a common clinic “module” for each practice. Flexibility is achieved through the ability to schedule patients into adjacent modules when available and to reassign modules to different services when workloads change.
Ambulatory Care 5
Source: Gary Wollard, AIA
.
One programming technique is to seek a consistent number of exam rooms for each module. Twelve exams is a “magic” number for this purpose since it is divisible into two six-exam room clusters, four three-exam grouping, or six two-exam pairs. Ten exams is another common module. Using a modular concept may mean there are miss-matches between the exact estimated need for a particular service and the exam room allocation. If these discrepancies create unacceptable functional problems then the modular concept must be modified.
Ambulatory Care 6
An example of a modular approach at the recently opened Samuel U. Rodgers Health Center in Kansas City (Raphael Architects).
.
Establishing functional efficency with each module include consideration of patient and staff walking distances, location of support functions, clustering of staff work areas and other considerations. The Facility Guidelines Institute recommondations for specific space programming should serve as a baseline for sizing a module. For a typical 12 exam room model we would expect to see the following elements:

  • Waiting – typically 2-5 seats per exam room, depending upon the type of service and the number of “escorts” accompanying a patient (such as in pediatrics)

  • Reception/registration – located adjacent to patient waiting, the required for this function will depend upon the level of computerization of records, fincancial payment collections, and on-site scheduling activities.

  • Vital signs – for adult patients this may include a scale and area for blood pressure check. For pediatric services there my also be a baby scale.

  • Exam room – this will be discussed in more detail later.

  • Clean utilities – basic supplies for restocking exam rooms and for other procedures performed in the clinic.
  • Soiled utilities – for disposal of liquids and holding of trash.

  • Nurse charting – these areas may be centralized within the module or dispersed next to the exam rooms.

  • Physician charting – this could be either individual offices for physicians based in the clinic or a multi-physican work room.

  • Procedure rooms – specialized rooms for procedures that cannot be completed in the typical exam room.

  • Toilets – typically one for every six exam rooms and at least one staff toilet.

  • Staff support – lockers, lounge, break area. These spaces can be shared between multiple modules.
Ambulatory Care 7
.
Ambulatory Care 8
.

Other methods for achieving flexibility are displacementand direct expansion, as illustrated in the diagram below.

Ambulatory Care 9Displacement relocates selected program components to allow for growth of remaining components into the vacated space. Adjacencies and circulation patterns are fequently compromised as a result of the relocations.














Direct Expansion allows for program components to remain in place and grow to the perimeter, maintaining adjacencies and circulation patterns.Ambulatory Care 10
















The Exam Room

The primary ambulatory site for patient care is the exam room. Activities that can occur within an examination room include data collection (history), vital sign measurements (blood pressure, weight, etc.), physical examination and consultation. Common components of the exam include an examination table, waiting chairs, a sink, supply storage and at least one computer workstation. Additional instruments and equipment may be housed in an exam room for specific specialties, such as opthalmology and ENT.Ambulatory Care 11
Observation of staff and patient use of these spaces have disclosed some key design considerations:
.
  • Handwashing – sinks should be located near the entry.

  • History /consultation – studies of communication between providers and patients indicate that maintaining level eye contact between the provider and patient can reduce stress and the “white coat” effect (status inhibition in communication). Positioning the data entry workstation and the seating for a patient should seek easy, direct eye contact.

  • Patient privacy – the exmaination table and entry door should be located in a way to minimize exposure of a patient to inadvertent visualization from corridor traffic if the door is open during an examination.

  • Exam table location – physicians are trained to approach patient from the patients right side. This defines a primary work zone for the provider. Depending upon the specific examination access to the head and left side of the patient may also be required. Pediatricians may examine and treat infants in a parents lap or on an exam table placed against the wall.

  • Supplies – the examination room should contain the minimum amount of supplies to support examination. Under counter storage should be discourages, particularly in pediatric examination rooms.
The optimal size of an examination room should be determined by the functional requirements of the activities in the room. For large clinics or medical office buildings, it is desirable to maintain a common exam room size for all services. The size and orientation of the exam room will ultimately influence building area and cost as well as travel distances in large clinics.
.
Example exam room
.
Exam room size comparision
.
Some organizations are exploring new concepts in exam room design. One model focused on the education and consultation role. The basis of this approach is that a very small part of a typical patient visit is the examination. Most of the contact time is spent in patient interview, consultation, and education. Yet, we design the examination room around the physical exam. Cerner Corporation in Kansas City developed an exam environment which separates the waiting, education and consultation functions from the direct exam.
.
Cerner Employee Health Center

As ambulatory care becomes a bigger component of healthcare we can expect futher research and experimentation in exam room environments.
.
The Medical Office Building(MOB)
.
Over the past two decades we have seen a major shift in physician practices from single providers and small groups to large group practices. The recently passed Federal Affordable Care Act further encourages the development of large group practices though the creation of Accountable Care and Medical Home organizations. In addition to the traditional office clinic model more specialized patient care environments are being created incorporating sugery, imaging, infusion therapy, and other outpatient procedures.

The mechanism for delivering the medical office building can vary from hospital owned buildings to physician and investor owned. Many development corporations focus on financing, building and owning MOBs. Quite frequently the focus of the developer and physician owned models is on first dollar costs. This can place significant pressure on the designer to maximize the utility of the available space while maintaining esthetic quality and accommodating long term adaptability.
.
MOB Layout
.
As practices and buildings grow increasingly larger it is common to see support diagnostic services incorporated into the design. For a multistory building these functions – imaging, pharmacy, physical therapy and other “retail” related health services are typcially located on the entry level of the building.
.
When medical office building are located on hospital campuses it is common to connect the MOB to the hospital, allowing physician and patient flow between the two functional areas. Master planning a campus to accommodate future gtowth of both the hospital and ambulatory care needs must be carefully considered in the site development. Ambulatory care buildings can be constructed under LifeSafety building code “business occupancy” criteria. These, and related building codes, are less stringent related to floor loading, building materials and other requirements. When planning for a constrained, urban site, some healthcare organizations have designed the medical office building to be adaptable for future conversion to hospital functions. This raises the first dollar costs, but provides an “insurance policy” for future growth.
Other ambulatory areas

As previsouly noted, there are a broad range of ambulatory specialty building types including freestanding urgent care centers, cancer centers, ambulatory surgery, and rehabilitation centers. Each area has unique functional and space requirements. We will discuss some of these areas later in the course. It is reasonable to assume that this area of healthcare architecture will continue to experience innovation and new design concepts resulting from the pressure to reduce healthcare costs, unique needs of the population (particlurly elderly) and the blurring of the lines with traditional hopistal functions.
Additional Resources:

See the Center for Healthcare Design web site on clinic design - http://www.healthdesign.org/clinic-design

[1] Vital and Health Statistics, Series 13, Number 169, CDC National Health care Survey.



More pages