Designing a New Ambulatory Care Delivery Model

A New Operational Model for Ambulatory Care Written by Eric Mayne, AIA, RIBA

The following article published in HC+O News on January 29, 2014. The University of Wisconsin (UW) Medical Foundation has partnered with Kahler Slater to design a new outpatient clinic that supports a lean and efficient operation ideal for staff collaboration and enhanced patient satisfaction. VISION The UW Medical Foundation identified a need to serve the growing communities along the Yahara River near Madison, Wis. The organization desired a solution that would meet the challenges of providing quality ambulatory care and acknowledge concerns of safety, privacy and the ongoing drive for efficient care with better patient outcomes. The family medicine clinic needed to include imaging, lab and physical therapy services, as well as health education support spaces. The UW Medical Foundation’s vision is patient-centered and qualityfocused. The organization decided to adopt the patient-centered medical home model of care to improve clinical quality by optimizing an integrated care team, increasing patient engagement and offering a holistic approach to patient care. With a visionary approach at the forefront, Kahler Slater designed the ideal space arrangement to support the operational model. Key to achieving the desired results was locating Integrated Care Team (ICT) space as close as possible to the areas where care is delivered. A new space plan was developed that places off-stage ICT space isolated from front-of-house patient amenity space and circulation. THE BIG IDEA When completely separating front-of-house and back-of-house in a clinic setting, the one place the two must overlap is in the exam rooms. The solution was to create double-sided exam rooms with a patient entry at the front and caregiver entry at the rear, allowing complete autonomy for both realms. Caregivers can collaborate within a fully integrated care team environment without concerns for privacy or interruptions, and patients are provided with a comfortable, hospitable environment away from the clinical environment with no overlap.

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Designing a New Ambulatory Care Delivery Model

OPERATIONAL STRATEGY The operational model flow supports voluntary self-rooming, which incorporates technology to assist with wayfinding. This results in creating a convenient, no-wait option for those who choose to self-room and reduced wait times for all patients.

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83% Reduction in footsteps ICT OFF-STAGE COLLABORATION SPACE One of the goals inherent in the ultimate design solution was to create efficient workflow by drawing physicians out of private office environments and into integrated team environments where collaboration and face-to-face communication are encouraged. At the UW Health Yahara Clinic, the design strikes the perfect balance between integrating physicians into the care team areas and also creating a private and secure environment so that patients’ cases can be discussed openly without confidentiality concerns. By centralizing these private ICT spaces and surrounding them with exam rooms, communication remains centralized and not spread out across the facility, which greatly reduces travel distances. During our research analysis, a footstep study showed that the clinical staff’s average walking distance from patient to support spaces was reduced by 83 percent.

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Designing a New Ambulatory Care Delivery Model

DOUBLE-SIDED EXAM ROOM Creating larger spaces for caregivers to interact with patients allows flexibility to provide a range of consultation environments. Rooms can be arranged as informal meeting spaces with soft furnishings, with an exam table for physical examinations, or grouped together to create larger rooms for educational group visits or group therapy. Each exam room has double-sided access, allowing patients and caregivers to enter and exit without crossing paths. A simple switchboard at the central reception desk that turns on a series of three lights lets caregivers and staff know that either the patient is in the room waiting to be seen, the exam is finished and the room needs cleaning, or the room is clean and awaiting the next patient.

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17%

Patient satisfaction increase for general reputation, wayfinding and the environment

REDUCED WAITING ROOM SIZE Historically, outpatient facilities reserve two chairs in the waiting room per exam and procedure room, and more recent recommendations are for one to 1.5 chairs. At the UW Health Yahara Clinic, less than one chair per exam and procedure room was provided. Those chairs support the hospitality station for early arrivers, rather than being used by patients waiting for an available exam room. This area reduction almost entirely offsets the increase in circulation surrounding exam rooms to achieve the self-rooming and private ICT environment. EMPOWERING THE PATIENT THROUGH THE USE OF TECHNOLOGY In addition to self-rooming for exams, a check-in kiosk is integrated into the reception desk where patients can announce their arrival for outpatient visit, diagnostic test, lab, mammography, x-ray and physical therapy appointments. Once checked in, patients proceed to the sub-wait areas or proceed directly to their appointment. The kiosk empowers the patient by providing another option that speeds up check-in and reduces wait times. If a patient does not desire to use the kiosk, a friendly staff member is only a few feet away to provide personal assistance.

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Designing a New Ambulatory Care Delivery Model

SETTING THE BENCHMARK The UW Health Yahara Clinic aligns with the Marketing and Planning Leadership Council’s November 2010 “Implications of Reform on Facility Design” imperative, which proposes necessary steps to achieve true national health reform. The new proposed standards aim to improve cost of care, patient access, workflow efficiency and coordination across providers and settings. Both Kahler Slater and the UW Medical Foundation are very pleased with the clinic’s plans for a smart future. CONCLUSIVE EVIDENCE One year after occupancy, we returned to the UW Health Yahara Clinic to complete a post-occupancy evaluation and found very positive results. Improvement in scores for the UW Health Yahara Clinic show a range from 12-22 percentage points for general reputation, wayfinding and the environment − proof that the separation of public and private functions allows for a clarity of wayfinding and for well-crafted public space that creates the best experience for the patients and visitors. An overall 25 percent increase in patient satisfaction scores was a clear signifier that this separation allows the caregiver teams to focus on giving the quality care that the UW Medical Foundation is committed to providing. In addition to the positive patient feedback received, we also heard overwhelming comments from the caregivers on their improved working environment, improved patient privacy, a reduction in interruptions to nurses, improved efficiency with close proximity to exam rooms, and an appreciation for the natural light and views out to nature from the working environment. The success of this operational model has elevated the UW Health Yahara Clinic to become a recognized benchmark facility for the delivery of ambulatory care.

CLIENT: UW Medical Foundation SIZE: 32,000 SF, Two Story COMPLETION DATE: 2010

KAHLER SLATER SERVICES PROVIDED: •• Programming •• Masterplanning •• Architectural Design •• Interior Design •• Lighting Design •• Environmental Graphic Design

DESIGN TEAM: Architect: Kahler Slater Design Build Contractor: Findorff AWARDS: •• ASID Gold Medal Award •• LEED Certified

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Smart thinking. Beautiful results! Kahler Slater was founded in 1908 and has more than 95 professionals and offices in Milwaukee and Madison, Wis. and Singapore. The firm’s mission is to partner with visionary clients throughout the world to bring their visions to life through total experience design. The health care team at Kahler Slater knows the issues facing clients today: you must be smarter, faster and leaner, improve clinical outcomes and achieve higher patient satisfaction scores, all in the face of a dramatically changing health care landscape and intense market competition. Team members enthusiastically partner with clients to face the future by designing health care experiences that are forwardthinking, highly efficient and beautifully differentiating.

Kahler Slater is an industry leader: from being a Champion Firm for the Center for Health Design’s Evidence-Based Design Accreditation (EDAC) program; to being selected as an inaugural member of the Planetree Visionary Design Network (one of only 13 firms internationally); to being named a national Best Place to Work 10 years running. Kahler Slater’s team of planners, architects, interior designers, clinicians, researchers, lean specialists, graphic designers and communications professionals work collaboratively to deliver smart thinking and beautiful results – every time.

For further information, please contact Eric Mayne, AIA, RIBA at [email protected]. Kahler Slater would like to thank Theresa Soik, Director of Facilities and Materials Management, and Lori Hauschild, Director of Clinic Operations with the University of Wisconsin Medical Foundation for their contributions to this white paper. This whitepaper was recently published by HC+O News, January 2014.

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