Will Changing Your Office Design Save Time and Improve Care?

Busy physicians are always looking for ways to provide better, more efficient care and the layout of their practice can facilitate that, say healthcare design experts.

They are turning to architecture firms that design medical practices using Lean workflow concepts and Disney’s on/off stage design that benefits staff and patients.

"The design we are using now has had a huge impact on the way we practice medicine. There's no question that we get patients in and out faster and my colleague and I finish up 45 minutes earlier, which would allow us to see two additional patients. Doctors and patients are more satisfied," says Kevin Ferentz, MD, the lead physician for family medicine at the Greater Baltimore Medical Center in Owings Mills, Maryland.

Ferentz says the design saves him time because his medical assistant is always nearby — either in the exam room or in an adjoining room 5 feet away where they share a workspace, which makes it much easier to communicate throughout the day and cuts down on the time spent waiting and walking.

Doctors can also save time in their day by using the adjoining room to return daily phone calls and call-in prescriptions throughout their day rather than returning to their offices or waiting until after seeing all their patients, says Robyn Dubick, a principal at CRGA Design in Baltimore who designed Ferentz's office and another family medicine practice at GBMC.

Another time-saver is the exam rooms have identical layouts and consistent places for supplies and equipment so doctors always know where they are.

Dubick incorporates Lean concepts aimed at improving the patient's experience and outcomes by increasing efficiency and reducing waste.

Patient processes have been streamlined to take place in the exam rooms. Patients can be checked in or out and have lab or diagnostic tests performed in their rooms, says Dubick.

GBMC has seen its patient satisfaction scores increase from 85% to 93%, she says. The higher the hospital's scores on the survey from the Centers for Medicare & Medicaid Services, the higher their Medicare reimbursements will be.

How Virginia Mason Inspired Design Changes

Ferentz says he learned about Lean management and the on/off stage design when he attended a workshop at Virginia Mason Institute in Seattle that showcases the medical center's dramatic transformation from a failing hospital to a successful one.

Since 2008, Virginia Mason's profit margins increased and deaths and medication errors decreased. Other reported benefits are an 85% reduction in how long patients wait for a lab result, a 93% increase in productivity, and a $1 million reduction in inventory costs.

While direct cost savings aren't passed on to patients with the new system, less waiting, increased safety, and more efficient care are.

But not all physicians and architects are a fan of the Virginia Mason design. Some have found that certain elements don't work well in practice, such as eliminating all windows or offices.

Ferentz misses having a private office. "That has been a source of contention with the organization. As the lead physician, I believe having some administrative space for the leadership would be valuable, whether it's to counsel another doctor or put a filing cabinet in."

Benefits of On/Off Stage

Dubick applies the "on/off stage" concept used at Virginia Mason to medical practices. "The purpose of separating patient and staff flow is to provide patients with the 'Disney' experience. This keeps all of the activity out of patient view, providing a calmer experience. Having staff circulate separately allows for the care team to communicate in a timely effective manner without the worry of patient interruption or accidental HIPAA violations," says Dubick.

Patients only see their hallway and exam/treatment rooms, which they enter from opposite sides from the staff along a U-shaped corridor. Physicians and staff use hallways, meeting rooms, and collaborative spaces that are not visible to the public.

The "on/off stage" design. The orange portion represents the on-stage patient space and the blue portion represents the off-stage staff space.

Scott Eden, MD, the lead physician at Chesapeake Family Medicine in Anne Arundel County, Maryland, says physicians preferred the on/off stage design because it was more efficient and provided more privacy than the traditional long hallways leading to exam rooms where doctors and patients comingled.

"Most striking was that the design helped us with HIPAA privacy issues. Before, patients could hear our phone discussions about other patients as they passed by or stood near us," says Eden. "But that problem ended with the on/off stage design."

Cons of On/Off Stage

Larry Brooks, an architect and president of Practice Flow Solutions in Atlanta, an architecture firm that designs and renovates medical practices, is not a fan of the on/off stage design and says he tries to talk doctors out of it.

"It uses more square footage and complicates communication by having two separate hallways for patients and clinicians. The nurses and doctors in the back may know which exam rooms their patients are in, and nurses often cut through the exam rooms to get from the back to the front. We can achieve a better functioning flow with less space," Brooks says.

He prefers using circulation paths, which he compares to streets in a town — some lanes have a lot of traffic (such as the check in and out areas and medical assistant stations) and other lanes don't (such as the hallway that leads to exam pods on each end that are like a cul-de-sac). He designs the more congested areas to have wide "boulevards" compared to the less congested "two-lane highways," for example.

The "circulation paths" design, as created by Atlanta architecture firm Practice Flow Solutions.

Patients and clinicians enter the exam rooms from the same hallway, which cuts down on the square footage and is less confusing for patients who are used to entering and exiting the same way, says Brooks.

If doctors want a private area to take a phone call or talk to other doctors, Brooks creates private alcoves off the exam pods rather than a separate hallway.

"I can't remember the last time I designed a private office," says Brooks. Instead, "the best solution I have found is lining the room's perimeter with — let's say five desks for five doctors — and putting a small conference table in the middle of the room. The doctors can turn their desks around and have a meeting or lunch break."

How COVID, Technology Have Affected Design

COVID's social distancing brought a lot of design changes to the forefront that affected waiting areas, says Dubick.

That's when more practices became interested in adopted Lean principles that minimized wait times for patients and brought them directly to the exam room, she says.

The pandemic also pushed practices to come up with safer ways to check patients in, rather than having them congregate at the reception desk. These included using an online patient portal or a self-service electronic kiosk, says Brooks.

COVID also accelerated the need to check patients out electronically in the exam room, much the way credit cards are handed off to waitresses at restaurants, says Brooks.

Electronic health records have also changed how doctors interact with patients in the exam room. Doctors who use EHRs on their desktops often turn away from patients, which reduces face-time with them, says Brooks.

To remove that barrier, the design may include a mobile cart in the exam room an L-shaped counter for doctors to place their computers; it depends on each practice, he says.

What Doctors Should Know About Practice Design

David Zetter, founder and lead consultant of Zetter HealthCare in Mechanicsburg, Pennsylvania, advises clients on the design/renovation process. He recommends these steps to doctors.

Ask yourself: What do you want to accomplish? That will drive the type of vendor you need to talk to and the permits you need, he says. "I have clients who redesigned with just a contractor while others have secured an architect, patient flow experts, and designers."
Use experts in healthcare who understand how medical practices work, what doctors and nurses do, and patient flow. That will help avoid costly mistakes.
Plan far in advance. Many firms have lost staff during the pandemic and may be backed up.
Be patient, especially if you're doing any construction because of supply chain problems. "It took 6 months for one client just to get a new door."

Ferentz appreciated having input into the design process from the beginning. Dubick says, "It should be a team approach with anyone who uses that space, including doctors, nursing staff, technicians and front office staff."

When it comes to costs, it's by the square footage. Dubick estimates the construction cost is $75-150 per square foot. "That is not the full-fledged architecture cost — it excludes design and additional equipment and furniture we buy."

Ferentz says the total cost of expanding the medical practice from 5 exam rooms to 18 is $4.5 million dollars. "We were fortunate to get a donation that covered all the costs."

The average time to complete the project is 12-14 months, says Dubick.

Ferentz is confident there will be a return on investment to his practice's new design because the practice is already booking patients into the fall.

He has no desire to work again in a traditional linear design. "I would be extremely unhappy if I had to return to those long hallways where I am on one end and the medical assistant is on the other end," says Ferentz.

Christine Lehmann, MA, is a senior editor and writer for Medscape Business of Medicine based in the Washington, DC area. She has been published in WebMD News, Psychiatric News, and The Washington Post. Contact Christine at clehmann@medscape or via Twitter @writing_health.

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