Grand designs

Medical facilities have a less than glowing history when it comes to design. Until relatively recently, hospitals were immediately identifiable by their monotonous corridors, sterile white walls, and heavy-handed use of concrete. The design backlash seen in the US in recent years has yet to fully hit the Middle East, where 'patient-friendly design' still typically translates to liberal use of scatter cushions and design features that drop off sharply once patients exit the waiting area. But it's an oversight that could be costing practices money.

It's not too strong a statement, notes Larry Brooks, senior design consultant for Medical Design International, to say that how you practice medicine is dictated by your clinic's design. Tip: it's not about the colour swatches.

"Physicians typically don't understand the link between how productive they can be, and the space around them," Brooks admits.

Physician and patient workflows are shaped by design, he explains, which can have a significant impact on your practice's productivity. If your clinic's design is flawed, you'll see the impact on your bottom line.

"A pretty building that is ineffective will lose you money. It's about designing workflow processes that are efficient, and wrapping the building around those; plan the function and then the aesthetic."

Physicians are typically slow to grasp this link, mainly because most designing a practice have never done so before, and probably never will again. And while some may baulk at putting aside budget for expert consultation, Brooks says, good design will pay for itself.

"Efficient workflows can increase revenue by 50-60%, which isn't unusual," he reveals. "Physicians often don't understand the economics of what their time is worth."

Shape of things to come

The cornerstone of good design, says Dr Tasnim Khan, partner at the American Family Clinic, Dubai, is deciding what you want to achieve with your clinic.

"From a physician's perspective, you want revenue, you want to keep your expenses down and you want patients happy," she suggests. "By looking at processes to improve the total patient experience, at the same time you're going to be able to minimise your costs."

Brooks asks physicians to determine the future goals of their practice. "How many providers do you want to plan for, and what services do you want to provide to your patients?" he asks. "That helps us understand where they want to get to rather than what they're doing now."

For first-time buyers, Brooks suggests taking a second look at the shape of the building before signing on the dotted line. "You don't want any space, or room or any piece of property that is more than twice as long as it is wide," he stresses. "The squarer the better, when it comes to the shape of your building. A long, skinny piece of property elongates the flow-patterns for the practice, which means you walk further to get the same work done. It's much less efficient."

This is a particular problem in the United Arab Emirates, suggests Simon Varghese of Dubai-based Evolve Interiors, as the property flurry has seen the number of available clinic spaces drop.

"Demand for space is outstripping supply, so tenants who get space are ready to get the money and sign on the dotted line," he says. "Then they find the building can't meet their requirements.

"It's the biggest problem in Dubai right now, so new tenants should really study space before signing up."

Architect Fareena Dawood has recently completed work on the American Family Clinic. To create a clinic that works for you, rather than against you, she advises heading back to the drawing board to establish your working patterns.

"Bubble diagrams are something we typically do for any project," she explains. "You identify spaces, such as exam rooms and the waiting area, and explore the relationship between them. Based on the priority between these relationships, you either put them together or further apart to ensure the functional aspect of the design is correct.

"Circulation is everything with a clinic."

Function versus form

For existing practices, there is a range of ways to map out workflows. Brooks, for example, stands in the hallway of practices and times physicians to identify how much of their day is spent in clinical practice, and how much spent searching for a nurse, walking the halls, or waiting for a patient to be brought through. The aim is to identify possible bottlenecks, and see how workflow could be streamlined by more supportive design.

The results are divided into three categories, Brooks explains; tasks only the doctor can do, tasks that could be delegated to another member of staff, such as collecting medications, and wasted time spent in the hall or waiting for a room to be set up.

"We see how the space is negatively impacting their ability to be productive," he notes. "When we show this to doctors, we say, ‘in the environment you're in; you're seeing four patients an hour, but if you eliminated this wasted time and delegated effectively, you could see six.'"

Few Middle Eastern design firms have healthcare-specific experience, Khan adds, so physicians should plot these workflows before bringing professionals on board. She recommends carrying out a patient-cycle audit to identify any snags in your average patient's visit. Just note the time taken to complete each stage on the patient's chart.

"For example, if a patient checked in at 3pm, we would note that check-in took four minutes. Then we'd mark down waiting time, time taken to transfer to the exam room, amount of time spent with the doctor and so on.

"It really gives you feedback, and it's an objective measure."
For Khan, patient audits informed her decision to ‘co-locate' a nurse station and receptionist on the practice's front desk. By putting a nurse at the centre of the action, it cut down on delays between patients and saved money on funding another member of staff to link the front desk and nursing station. In medical parlance, it was a ‘high-yield' move.

"The nurse picks up where the administrator leaves off," Khan explains. "She knows patient A is ready to be seen and has been checked in. If you only have a nurse located in the back, there is less communication with the front desk, which can lead to patient delays and duplicated paperwork.

"This cuts expenses, increases revenue and efficiency and makes patients happier. It means I can run three exam rooms."

Efficient patient flow, says Dr Chris Canning, medical director of Moorfields Eye Clinic, was the deciding factor in his facility's design. The clinic features a circular floor plan, so patients follow a logical path during their appointment. The first stop is the reception area, which leads on to check-in desks where patients are booked in. Patients are then led in to a waiting area, which is surrounded by closely linked examination rooms. Each pod has a light above the door, which is activated once the attending nurse or physician inserts the patient's individual smart card into the computer.

"Staff can see at a glance which rooms are occupied," Canning explains. "It means patients aren't disturbed during their consultations."

This clustering of exam rooms, says Brooks, is crucial in maximising efficient patient flow, adding that physicians need at least three exam rooms for top revenue results.

"Space can really have a negative impact, when you see how much walking is done outside exam rooms just to get to the next patient, or to find a medical assistant or a nurse to request information," he explains. With clustering, physicians can move quickly from one room to another, while minor tests and work-ups are handled by nurses. Brooks advises locating rooms across the hall from each other rather than in a line, and mirroring the same layout in each. "Get the space as square as you can and make every exam room the same," he says. "It eliminates the doctor having to search and become reoriented each time he or she changes room."

By helping clinicians maintain top productivity, careful design means more patients can be seen per day, boosting revenue. "There's no insurance code for walking the hall," Brooks tells his clients. "You're not getting paid. No productive work is being done walking."

Moorfields has taken this on board, creating a second, hidden corridor that links behind the exam rooms. This path, Canning says, allows staff to flit between rooms without crossing the central waiting area. "The idea is to keep the room as tranquil but efficient as possible, to minimise stress for waiting patients, " he explains. Digital whiteboards displayed in the corridor allow staff to see immediately which patient is in which pod, and how long each has been waiting, while a nursing station ensures assistance is close by.

The waiting game

First impressions count, so your reception area should appeal to your patients. Low-budget tips include using soft lighting, arranging chairs in pods rather than in lines against the wall, and using warm colours. For practices with a healthier bottom line, waiting rooms can be used to showcase the clinic's culture. Dubai Bone and Joint Clininc is a case in point. Ben Corrigan, senior design manager at interior design firm Bluehaus, headed up the design of DBAJ. The walls of the clinic are covered in white circular discs, picked out with lighting, which were selected to reflect the practice's investment in gene therapy. "They wanted the experience to start as soon as patients entered the reception area," Corrigan says.

The optimal size of the waiting area depends on the number of patients you expect to see. A helpful formula is to take the number of patients you expect to see at peak times, and multiply that number by 2.5 to accommodate any accompanying friends or family. Then subtract the number of exam rooms you have. This gives you the number of chairs you need. Next, multiply your total number of chairs by 20 sq ft; that's the estimated size of waiting room you'll need.

Dawood designed AFC's waiting area with one eye on the patient demographic. "We wanted a large waiting area, so a large percentage of space is used in the reception," she explains. "We wanted a separate play area for children, so we dedicated an area behind a curve wall for them. We also have an area that is designed for adults."

The adult section features a wall-mounted television that provides a running commentary of the latest health news, courtesy of news channel CNN. The children's play area, meanwhile, combines wall-mounted toys with an aquarium to occupy younger patients.

The walls between the examination rooms and the reception area are sound-proofed, adds Dr Alya Ahmed, a partner in the practice. "This is both for privacy, and because children can be startled if they hear another child undergoing a procedure he or she is frightened of."

For larger practices, the key is to ensure patients are orientated as soon as they step inside the building. Confusion breeds dissatisfaction, Brooks explains. "In surveys, satisfaction with that practice goes down because the total experience was not very pleasing. From the operational side, if your patients have to request help, somebody has to spend time explaining to the patient how to get out of the facility, or how to find the examination room. Time costs money."

Form and function can partner here to improve patient flow. Aesthetics such as lighting levels and memorable design features can be used to guide patients around a facility.

"If the design is effective, you can use space to help keep the patient oriented," Brooks says.

Technology tips

The use of technology in your practice design can make a huge difference to production levels. Brookss is an advocate of signalling systems; "Anything where you don't require somebody to physically walk somewhere to tell another member of staff something," he explains.

Appointment scheduling is a sticky area for many clinics, as support staff struggle to bring patients in at the correct rate. Doctors can find themselves loitering in the hall, waiting for their next patient, while nurses can create patient bottlenecks when appointment slots run over. Khan has evaded this problem, by installing messenger services in the practice. Once a patient has arrived and is ready to be seen, she receives an alert on her laptop. During appointments, she receives updated alerts to tell her the next patient has arrived, or to flag up any urgent issues. Khan credits the system with helping her run three exam rooms.

"If I am with patient A who, say, has a cold, the nurse can message to tell me that patient B has arrived without knocking on the door, calling or interrupting the appointment. I can message back to ask the nurse to complete, say a strep culture for patient A, while I start the initial consultation with patient B. When the test results come back, they can be sent to my laptop, and I can return to patient A while patient B is undergoing tests and patient C is being shown to the exam room."

This is a prime example, says Brooks, of how workflows can be supported by good design.

"So much of the doctor's time can be wasted because they don't have the right communication system," he notes. "Now they're seeing another patient or two an hour; that can be another seven or eight a day, they're getting revenue from ancillary services such as MRI or labs. The economic trickle can be substantial."

Future plans

Flexibility can be the most difficult design element, but final decisions should be made with an eye on the future. Construct spaces that can be easily altered to accommodate changes in your practice style or services.

"Plan for four, five years down the road and design space you can change if need be," Brooks says.

Whether starting from scratch, or upgrading your existing practice, Brooks recommends keeping one mantra in mind; your building can dictates your bottom line.

"Focus on the function," he concludes.