Woodway Internal Medicine Programming By: Molly Spear Fall 2013

Table of Contents
Introduction........................................................................................................................1-8 Information about the study.......................................................................................2 Overview of the state/town/demographic................................................................3 Client needs.................................................................................................................. 4 Methodology................................................................................................................ 5 Analysis of questionnaire........................................................................................... 6 Issues, goals, requirements......................................................................................... 7 Organization information.......................................................................................... 8 Research............................................................................................................................ 9-11 Observational research..............................................................................................10 Summary of findings.................................................................................................11 Current Building............................................................................................................13-14 Current photos...........................................................................................................14 Precedent studies........................................................................................................... 15-29 Literature review...................................................................................................16-17 Image search...............................................................................................................18 Summary of findings.................................................................................................18 Visit another location............................................................................................... 19 The Program...................................................................................................................21-25 Project Mission.......................................................................................................... 22 Square footages...........................................................................................................22 Space utilization and adjacencies.............................................................................22 Prototyping Sketches.................................................................................................23 Bubble diagram..........................................................................................................24 Conclusion..................................................................................................................... 25-27 Limitations and recommendations......................................................................... 26 Summary.................................................................................................................... 27 References....................................................................................................................... 28-31 Appendix A: Bibliography........................................................................................ 28 Appendix B: Questionnaire......................................................................................29 Appendix C: Building and Site plans...................................................................... 30 Appendix D: Articles for literature review....................................................... 31-50

Introduction

Information about the study

It is important to have a well designed healthcare facility for many reasons. It makes the facility look more professional, it can help you get business if your building looks as good as your staff is, and it also calms the people coming in for treatment. Many people have anxiety about going to the doctor and a calming atmosphere can help that. Also some colors have been proven to promote healing and if there is any place healing should be promoted it should be healthcare facilities. Woodway Internal Medicine located at 4000 W Woodway Drive in Muncie Indiana 47304 is the focus of this programing document. This group of professionals wants to create a building that shows off their mission and values. Woodway is a medical clinic comprised of 38 employees ranging from doctors to office workers that supply medical attention for adults in the Muncie area. This program is being done for a senior level class for Interior Design at Ball State University during the fall 2013 semester. The professionals want to create a center that promotes wellness, professionalism, and sustainability. The main problems that will be researched for this project are updating the overall look of the building and making the space more efficient for the workers and visitors. The building is currently a one story building located west of the Ball State campus and they treat anyone from 18+ mainly Muncie residents. The doctors, nurses and other staff work very hard to maintain HIPA regulations as well as treat many people in this tight and hectic space. There is a great need to redesign this space and obtain some growth in order to make this a relaxing and safe place for the staff and patients.

Map of location

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Demographics of Muncie
City Incorporated: 1865 City of Muncie Population: 67,430 Delaware County Population: 118,769 Muncie, in Delaware County, is located approximately sixty miles northeast of Indianapolis and is bounded by Grant and Blackford Counties on the north, Jay and Randolph Counties on the east, Henry County on the south and Madison county on the west. Since its organization in 1827, Delaware County has grown from a small Indian village to an important manufacturing center. The County was named for the Delaware Indians, an Eastern tribe which was slowly pushed into Ohio and finally settled in east central Indiana during the 1770's. The Delaware Indians established several towns along the White River, among these Muncietown, near present day Muncie. In 1818, under the Treaty of St. Mary's Ohio the Delawares ceded their holdings in Indiana to the United States government and moved westward. In 1820, Delaware County was opened for settlement.

Conclusion of demographics
Based on this research Woodway is aiming their efforts toward the most percentage of the population. 82.2% of the Muncie population is 18 and over which is what they treat at Woodway. Muncie has a higher percentage of adults in that category than Indiana in general which could be to Woodways benefit. The only thing Woodway could do differently is advertise to students of Ball State more since most of the students are from out of town. This could get them more patients because most students on campus probably do not realize that they have options besides Ball Memorial Hospital to get treatment for something that is non-emergency.

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Client Needs

Observations upon seeing the space is that everyone is overcrowded with a lack of space. Major things that they need are better circulation, acoustics, storage, lighting and privacy. There needs to be a major over hall in their space so that the function and the amount of space each person has is improved. With the average patient also being 70 the whole place needs to be universally designed while making everyone feel relaxed and safe in the space. Other things noticed that could be on this list are listed below: The view you see out the window is the parking lot which is not intriguing. The lighting is dim and there is little to no sun light coming in the windows which would be beneficial. There should be something besides the T.V. to look at since some people do not like the T.V. and it also gives the people in the waiting room either something to think about or something to look at. There should be some sort of white noise in the room because you can hear conversations even if you were trying not to listen which makes this facility not up to HIPA guidelines.

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Methodology
Ball State interior design student began by studying overall healthcare design. After becoming familiar with that the class then toured the facility. The students were shown every room, what was held there, who worked in that space, and what they needed for that space to work better for them. One of the doctors even had a question and answer session later in the visit. See page 10 for more details on this. Once the visit was completed the class put together a questionnaire was put together of all the questions that were not answered during the tour. One of the classmates then took the questionnaire to a head of Woodway and asked her all of the questions. Each student then did their own analysis of the responses. See page 6 for further details on this part of the process. After this was done clients wants and needs were evaluated and listed out to have a visual (located on page 4). Then design requirements were prioritized and concerns were identified. This lead to many hours of research which included literature reviews, observation of Woodway as well as similar healthcare facilities in order to find a solution that best fit the clients needs and wants. Mentioned above observations were done where the student revisited Woodway and watched how every one interacted with the space and to find unmentioned wants and needs. Then afterward the student analyzed this information to come up with their own conclusions. This observation is described on page 10 and 11. Each student then quickly came up with their own ideas of how things should be organized based on bubble diagrams, criteria matrix, and research of other facilities. Everything was then concluded and combined in to this booklet that the owners of Woodway can use to decide on what needs should be addressed and have an idea on how they can be achieved.

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Analysis of the Questionnaire

Questionnaire is located in the Appendix section under Appendix B: Questionnaire on page 29 Most of the questions the class came up with for this space were answered during the tour but there were a few left so a classmate went to ask the questions on the questionnaire. The answers that she came back with were pretty much expected but they did help to know what exactly they were thinking. More emails from the rest of the staff would have been helpful also maybe some of the visitors that come to Woodway. Including a coffee and juice bar would also be a nice touch of enjoyment for patients waiting. According to the survey, the amount of space and requirements such as power seem to be adequate at its current level. The location and space planning of the office seems to be fine for the employees.

Responses From Employees

I would very much like to see ergonomically correct front office updates for the check in and check out staff. Currently they have a terrible set-up that just might encourage the problems with repetitive motion coplaints, headaches from poor design of work stations, etc. Thank you for your interest. One thing that I would like to change about the office is to have actual desks in the check out and check. It seems like we have more like a kitchen counter top and there is no room to put your legs under the desk unless you put your chair very low and then it is hard to type if your chair is almost to the ground. Possibly more privacy at checkout or an advanced check in system in the waiting room. I would like to see the insurance dept. have a confidential/quiet area to be able to sit and discuss billing issues with patients. I dont feel it is appropriate to have disgruntled patients putting on a show for other patients trying to leave, pay, check out or have a procedure scheduled. Thanks

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Issues, goals, requirements

This was formed to figure out what the main issues were for the facility and then to figure out what the goal would be to fix that issue. The most important starts at the top with Privacy and so on down to Image being the last but still very important.

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Organization information
Numbers
Practice Mgr.- 1 Front office Mgr.-1 Billing- 6 Front desk- 7 Lab- 3 Nursing- 11 Physician- 6 Cleaning- 3

Analysis
Based on this chart the Nursing area, front desk and billing hold the most people so they should be some of the largest areas. But as you can see on the floor plan (see appendix C on page 30) they have the smallest area in overall square footage.

Woodway Business Mission

To promote wellness and prevent illness in adults To serve our patients in a courteous, professional manner To let our patients know they are valued, while developing longterm relationships with each individual. To offer state of the art care with minimum discomfort To promote regular preventative care in our office and at home so our patients can enjoy a lifetime of good health. To have highly motivated employees by providing an enjoyable and positive atmosphere for them to work in

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Research

Observational Research
Walk-through
The class observed the Facility of Woodway near the beginning of the semester. A tour was given by some of the staff as well as sat down with a doctor at the end there was an interview of a doctor and one of the nurses about what they were looking for out of this project. The wants and needs chart was then created and is located in Chapter 1 that lists out the wants and needs of everyone that uses this building from day to day. Additional notes are that the entire space was very dull and dim and needs to be opened up and expanded. The space is also very crowded with so many people working on top of each other. The possibility of expanding both up and out will be researched.

Behavioral Mapping

Location: Woodway Internal Medicine Waiting Room Date: Monday, September 9th, 2013 Time: 4:00-4:30 PM

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Location: Woodway Internal Medicine Waiting room Date: 10/12/13 Time: 12-12:30pm

Summary of Findings
If possible people will not sit near someone they do not know. Not many people watch the T.V. or use the magazines provided. Even though they do not see children, they do come and they need something to entertain them. People also would rather sit on the edges of the waiting room than the seats that are located in the center. When people come to the window to talk to the people in the office they tend to talk very quietly so that other people do not hear their conversation.

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Current Building

Current photos

3
1. The check in station from the waiting room 2. The check out station from the hallway 3. Storage and a very small office 4. The check out station from behind the desk 5. Storage area for files 6. The waiting room Some of the class was not allowed to take pictures on the tour while others were so these photos are from Megan Bates.

List of Photos

6
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Precedent Studies

Literature Review See Appendix D: Articles for Review on page 31

Article 1: A Material Challenge from Healthcare Design This article talks about the materials that are to be used in healthcare. They say to stay away from fire retardants because they start to degrade right away and can get on patients hands which makes them sick. Also stay away from performance compounds although they make material stain and water resistant. This material is found on nonstick cookware. Polyvinyl Chloride is inexpensive and is best used on floor and fabrics in healthcare. Many people are trying to find a material that will be safe to use and easy to make so it will not be expensive. Article 2: Breaking Down the Options This article talks about research methods that are beneficial to healthcare design. They say to look at case studies and see how they designed their space and what you could do in your space or what you could do to make the case study better in your design. Post-occupancy evaluations are also very important because they show you what the end users think of the project as well as how your design is functioning and hospitals are first and foremost function based. Prototyping is also helpful because you can see smaller scale versions to make sure that the space is going to work and this also helps the doctors understand what you are trying to do. They can correct something before it becomes permanent and a large issue. Article 3: Six Ways to Improve Doctors Waiting Rooms This article has many great things to think about when designing a waiting room. They want you to rethink the waiting room. It mentions that waiting in the doctors office is like waiting in the DMV or going through airport security. The first way is by comfortable seating but what is comfortable for one person could be very uncomfortable for someone else so there should be various sizes, shapes, padding, and adjustability to allow for people to make them-selves comfortable. The second way is to create a way for people to hang out in other locations away from the waiting room but be able to know when it is their turn to go in. This could be an app on their phone or some other way. Third should be clear medical records that are easy to understand and fill out as well as medication information and appointment reminders. Fourth is installing vending machines that offer healthy food while you wait so that it emphasizing the idea of eating healthy. The last two ways are to have welcoming signage to make the rooms feel more welcome and also give information like yoga for seniors or pregnant women and cooking healthy information. Article 4: Designing an Ideal Exam Room This article talks about how exam rooms should be capable of interaction, privacy, efficiency and accessibility. It should have work zones much like a kitchen but also be very flexible so that the room could be shifted for changing needs. Having an uncluttered exam room while also using calming colors, art and lighting provides ample support for the doctor and those being examined. The size of the room should be 8x10 or 10x10 but could be larger or smaller depending on what is happening in the room. Ease of access to a patient is critical because the doctor needs to be able to get to all locations on the body without making the patient move so no not injure them. The space should be arranged around the table. It is important to ask the practitioners what they are looking for and what they need in the space.

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Literature Review See Appendix D: Articles for Review on page 31

Article 5: Efficient Office Design for a Successful Practice First impressions count in an office because they should be similar to a hotel lobby. Patients comfort should be priority when designing the waiting room because overcrowding is awful but seating capacity should also be ample. Patients are reluctant to share seating like a couch so those should be eliminated and armless chairs can be useful for those who are pregnant as well as those who are overweight. Exam rooms should be a little more spacious than what you originally believe you need to allow for technology that will come in the future. Also wheelchair accessibility should be considered while designing. Consider the furniture in the exam rooms such as the exam table, seating, lighting, cabinetry, possible dressing areas and waste receptacles. Article 6: Planning and Designing Highly Functional Nurses Stations This is always the point of intensive and hectic action. Nurses will be trying to find out information as well as answering patients, phones, and each other in this location. This location should be centralized with quick asses to peers and resources. But it could be decentralized by locating them throughout outside of each unit. They should be flexible for the growing technology and changes in care delivery. The environment should be considered to support the users based on the type of hospital and the roles that the nurses take on. There should be a combination of the centralized and decentralized areas to make the most of the nurses station. Article 7: Nurse Station Design This also talks about the centralized and decentralized nurses station. They say to allow for flexibility, the work processed, adjacencies, collaboration, and reducing cognitive load. A station is located at some point of every floor and they are often also used for meetings. They should be clean, beautiful, and functional. Better stations can reduce stress and fatigue as we as improve patient safety and overall healthcare quality. Article 8: Means of Egress The definition of means of egress is a continuous, unobstructed path of vertical and horizontal exit travel from any occupied portion of a building or structure to a public way. The flow should lead from an area straight to the outside and a save destination. Other paths that lead to the same location are necessary in case the path is blocked. The codes book talked about the three basic components to a means of egress: the exit access, the exit and the exit discharge. Egress also includes information such as minimum ceiling heights, elevation changes, occupant loads, and width of egress.

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Image search
The images chosen were based on what the client wanted the space to look like as well as ideas to make the space more efficient. The pictures all show different parts of the space and they all give a similar feel.

Summary of findings
There are so many options now when designing healthcare because the industry has boomed. There is all sorts of new information out there about furniture, color choices, and physiology of healthcare. So many new products have been made to further the efforts of doctors and nurses to help encourage healing and to make it easier to give the care that the patients need. Some of my pictures show products such as larger chairs to accommodate many sizes of people, lamps that give off closer to daylight instead of florescent, and new ways to make signage easier to read.

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Visit of another location

Ball Memorial Hospital

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The Program

Project Mission
The mission of this project is to use the space allotted in a more efficient manor as well considering expanding both up and out. The space needs to be welcoming, calming, and encouraging healing. All information must be safe for HIPA regulations as well as for the sanity of the patients. Professionalism should be of the up most importance in every aspect that goes in to Woodway.

Space utilization and adjacencies

Square-footages
Current- Unknown Estimated- +4525 sqft

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Prototyping Sketches

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Bubble Diagram

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Conclusion

Limitations and Recommendations

Some limitations that need to be looked at are the land that can be built on or if building up is the better option. With building up many things need to be looked at and researched. Structural security, means of egress, and accessability all need to be researched. My best recommendation is that the business builds up. They move the doctors offices and billing up to the secons story since these spaces would not need to be acessed by patients as much as other parts of the building. The building should be taken down to the studs to make sure that the layout works best for everything and then the second story added on. There should be much planning and consideration on where to locate everything past my research located in this book.

Summary
In summary designing this space takes many hours of research, planning, and much more. Doctors offices are very difficult to design and take so much more than I would have ever thought was needed. I only scratched the surface of the research that needs to be done before ground is even broken on this project. I hope that the owners of this office can use this research as a starting place for their own research and planning for this project. These 50 pages are only the start of all the research needed.

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References

Appendix A: Bibliography
2006 IBC Building Codes pages 20 25. Means of Egress. A Material Challenge from Healthcare Design. <i>Healthcare Design Magizine</i> Jan. 2013: n/a. Print. Bajaj, R., & Bromberg, J. (2006, November 1). Planning and designing highly functional nurses stations. Retrieved from http://www.healthcaredesignmagazine.com/article/planning-and-designing-highly-functional-nur es-stations Breaking Down the Options. <i>Healthcare Design Magizine</i> Jan. 2013: n/a. Print. Color Psychology - The Right Colors for the Right Office Environment | Optos Blog. <i>Optos Blog</i>. N.p., n.d. Web. 3 Dec. 2013. &lt;http://blog.optos.com/index.php/color-psychology-the-right-co ors-for-the-right-office-environment/&gt;. Home&InteriorDesignIdeas. <i>The Worlds Most Stylish Surgery Clinic (Visualized)</i>. N.p., n.d. Web. 3 Dec. 2013. &lt;http://www.home-designing.com/2011/04/medical-building-surgical-clinic-interiors&gt;. Kaiser South LA Medical OfficeBuilding. <i>Kaiser South LA Medical Office Building</i>. N.p., n.d. Web. 3 Dec. 2013. &lt;http://www.dpr.com/projects/south-la-medical-office-building&gt;. Labarre, S. (2011, August 16). Six ways to imporve doctors waiting rooms. Retrieved from http://www.fastcod sign.com/1664797/six-ways-to-improve-doctors-waiting-rooms Marquette General Health System MOB, Escanaba, MI. <i>Duke Realty</i>. N.p., n.d. Web. 3 Dec. 2013. &lt;http://www.dukerealty.com/client-experiences/2013/02/marquette-general-health-system-mob-escan ba-mi/&gt;. Muncie (city) QuickFacts from the US Census Bureau. <i>Muncie (city) QuickFacts from the US Census B reau</i>. N.p., n.d. Web. 3 Dec. 2013. &lt;http://quickfacts.census.gov/qfd/states/18/1851876.html&gt;. Other Medical Facilities Architecture and Design | Boulder Associates, Inc | Boulder Associates, Inc. Other Me ical Facilities Architecture and Design | Boulder Associates, Inc | Boulder Associates, Inc. N.p., n.d. Web. 3 Dec. 2013. <http://www.boulderassociates.com/portfolio/other/>. Staples. (2010, November 10). Designing an ideal exam room. Retrieved from http://www.staplesadvantage.com what-we-offer/furniture/news-articles/designing-exam-room.page Tolson, N. (2012, June 17). Nurse station design. Retrieved from http://www.array-architects.com/nurse-st tion-design/ Wells, J. (2005, May 14). Efficient office design for a successful practice. Retrieved from http://www.aafp.org fpm/2007/0500/p46.html

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Appendix B: Questionnaire
*The regular text is the questions and the italic text is Vickis answers. *This interview was conducted on September 23rd, 2013 at 2:00 pm. Employee Demographics List office staff, secretaries, medical staff, non-medical staff? How many part time? How many full time? Do you have a hierarchy chart to portray this information? Vicki emailed me a List of all employees, their schedules, and positions. Waiting Room Are there additional activities you would like to see provided in the waiting room? What activities? (TVs, Play Area, Educational Videos, Etc.) One of the nurses has toys in her office that the children can play with while the patients are in their appointment. There is currently no toys set up in the waiting room because not many children come in. Music or other activities would be welcome in the space. Equipment Do you have any equipment that needs special accommodations? Is there any equipment you need but cannot have due to spatial or electrical limitations? They have a bone density machine that requires electrical accommodations because it uses more power. It has its own electrical box. The lab area also has equipment that needs upgraded power to run. There is no other equipment that they cannot have due to spatial or electrical limitations. Functionality of Space Are there any rooms that would benefit from being located in closer proximity to each other? The current proximity of rooms in the facility is good. If special arrangement is altered, however, two proximetrics must be kept in mind: o The drawing room (Phlebotomy) must be close to the lab o The drug room should be accessible to all nurses and physicians (i.e. central location) Building Information/History Do you have the original construction plans with section cuts? None that Vicki is aware of but she will check with Sher (spelling?) Construction who did their remodel and get back to us. Existing Problems What is one significant design change you would like to see happen in this space? Vicki would like to see the front desk and check out area be more HIPA compliant (privacy issue) Are there any business changes that you predict will take place in the next 5 years? (Long term goals) They would like to add 1-2 nurse practitioners to their team but their current space will not allow this expansion. They would need more exam rooms for this to be possible. *I had Vicki send out the following question through email to all employees at Woodway: What is one significant design change you would like to see happen in this facility?

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Appendix C: Site plans

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KEY

Exam rooms Doctors oces Nurses stations Waiting room Check in and out Other

Appendix D: Articles for Literature Review

Article 1: A Material Challenge from Healthcare Design (page 32-33) Article 2: Breaking Down the Options (page 34-37) Article 3: Six Ways to Improve Doctors Waiting Rooms (page 38-39) Article 4: Designing an Ideal Exam Room (page 40-42) Article 5: Efficient Office Design for a Successful Practice (page 43-45) Article 6: Planning and Designing Highly Functional Nurses Stations (page 46-48) Article 7: Nurse Station Design (page 49-50) Article 8: Means of Egress (page 50)

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Article 1: A Material Challenge from Healthcare Design

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Article 2: Breaking Down the Options

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Article 3: Six Ways to Improve Doctors Waiting Rooms

Waiting endlessly in a doctors office ranks up there as one of lifes premier annoyances, right alongside queuing up at the DMV and getting manhandled at airport security. Short of overhauling our overstretched health care system, though, the problem isnt going away anytime soon. Luckily, design can make it a hell of a lot more tolerable. So suggests Fuelfor, a Spanish design consultancy, which compiled a case study on "Rethinking the waiting room." Research has shown that a well-designed waiting room -- one that includes everything from comfortable chairs to clear signage to easy-to-use patient response forms -- can bolster how patients feel about the care they receive and even streamline the care process itself. Fuelfor has identified six ways of dramatically improving waiting rooms. We've summarized them below: Comfortable seating Waiting when youre sick is bad enough. Waiting in a crappy chair when youre sick is downright galling. Whats more, whats comfortable for one patient might be deeply uncomfortable, or even painful, for another. Fuelfor proposes a modular seating system, called MODU, that can be adapted to different offices and individuals. Movable armrests and seating pads with various amounts of cushion let people create their own little comfort zone. Planters keep the air feeling fresh and displays at the end of each bench apprise patients of their wait time. Acoustic separators eke out space for private phone calls. Manageable queues Queue management displays in waiting rooms make people feel physically tied to one spot, Fuelfor writes. Taking a number isnt much better -- its impersonal and disposable (not unlike your average doctors appointment). Fuelfors solution: feature wait-time displays prominently in multiple places, not just over the central counter. People who dont want to hang around the waiting room can download Inline, a conceptual iPhone app that reveals their number in the queue with a clear, simple interface. It also lets patients book appointments, locate the room of their appointment, and track medications, among other health-management features. Clear medical records More and more, medical records are going digital, but Fuelfor suggests a low-tech alternative to ensure that people can simply and viscerally manage their own health. With FOLIO, patients store their medications and appointment dates in paper wallets that be thrown in a purse or back pocket and carted easily to the doctors office. At the office, they use the FOLIO info to fill out Prepare, a patient-response form that asks simple questions in a clear format designed to prevent mistakes. After the appointment, doctors fill out a separate Remember form that includes prescriptions and other health advice. It might sound like a lot of paperwork, but with good graphic design, it can actually feel pretty simple. Healthy food Its always hilarious (in a depressing way) to see vending machines full of chips, candy, and soda at medical clinics that are supposed to be billboards for healthy living. Fuelfor conceived of a vending machine that dispenses water, apples, and other nutritious snacks while you wait. Its even designed like a kitchen counter to emphasize the idea that smart eating starts at home. Welcoming signage Doctors waiting rooms can feel terribly impersonal and bureaucratic. To inject a modicum of humanity, Fuelfor recommends throwing up welcome boards that introduce the doctors on duty (complete with portraits, so they arent just faceless names) and post information about healthy activities and classes, like yoga for seniors and cooking lessons.

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Communal space Fuelfor says that communal tables can help reduce patients anxiety in a waiting room. Were not totally sold on this one. People like privacy. Especially sick people. Then again, if youre at the doctors office with your family, a large table where you can gather and discuss sensitive medical problems makes a lot of sense. It could also figure prominently during medical consultations (just as long as it isnt, you know, too communal). Think about it: Instead of parking it on an examination table while your doctor dispenses advice that you cant even pay attention to because you feel so awkward in your ridiculous little gown, you could meet at a big, roomy table -- clothes on, dignity intact.

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Article 4: Designing an Ideal Exam Room

The design of your exam room is important no matter how large your practice is. The ideal exam room takes into account patient and caregiver interaction, privacy, efficiency and accessibility. "An exam room can be very much like a well-designed kitchen-with functional work zones, quick and unhindered access to work areas and effective organization," says Karen Edmundson, a furniture sales executive with Framingham, Mass.-based Business Interiors by Staples. A well-designed exam room can go a long way to minimizing "white-coat syndrome" and helping the patient feel less intimidated. If a patient and caregiver feel as if they can communicate in a more collaborative manner, this fosters more open communication, adds Edmundson. "Providing an interior environment that is soothing through the effective use of colors, art and lighting will also help to make a patient feel more comfortable," she points out. Flexibility is the most important element in the exam room for Troy Chapman, executive project manager at Austin, Texas-based general contracting firm Burt-Watts Industries. "That means the room can be shifted for changing needs," he explains. "It's a room with many different functions serving people with very different needs. Thus, it must accommodate all shapes, sizes and ages." A cluttered exam room is the last thing any practice wants. Storage, cleaning, and diagnostic areas must have enough space and accessibility for a medical staff to work. "It should also be welcoming to partners in care by providing ample room for their supportive role," Chapman adds. "And it must be thoughtfully designed keeping in mind all of whom use the space." A medical practice should consider the following elements: Size of the exam room For medical office architect Wayne Lerman, president of West Long Branch, N.J.-based W. Lerman Architecture, the ideal exam room should be sized appropriately to accommodate the type of practice you have whether it's orthopedic, cardiology, ophthalmology, pediatric or some other specialty. "Know the type of practice to properly size the room since they vary based on the type of patient," Lerman says. "We normally go with an 8x10 or 10x10 sized room. Sometimes it may be an 10x12 or 8x12-that's just a range for a typical exam room. Other types, like an ophthalmology practice, get into unusual sizes. For instance, the distance to the eye chart on the wall has to be at a certain distance, so these rooms are more rectangular in size, like 10x14." With minimal square footage available for exam rooms, Chapman says that it's especially important to make them as efficient as possible. Consistency in the building or renovation of exam rooms is also crucial. "Physicians and nurses often prefer examination rooms that are built or renovated the same," Chapman says. "This consistency allows them to find supplies easily and quickly, no matter which examination room they use." Ease of access to a patient The position of exam table is critical for doctor movement. "In an orthopedic practice, the doctor has to walk all the way around an exam table," says Lerman. "The table can't be pushed up against the wall because they may need to gain access to somebody who has a break or fracture." On the other hand, in a pediatric practice, the exam room can be pushed up against the wall because it prevents a child from falling off the table. In an OB/GYN practice, the exam table has to be positioned in a diagonal from one of the corners of the room. "Plan your space around your exam table," Edmundson advises. "Adjustable height tables will enhance flexibility if your rooms are used for a variety of procedures."

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Lighting Lerman likes to use lighting to create interest for the patient and a better environment for patients and staff. Again, the type of lighting you use depends on your practice. "In an ophthalmology practice, we use an indirect light in the ceiling because they like to lower the light level," Lerman says. "They don't like it to be very bright, so with an incandescent light, you can lower the light level." In most practices, Lerman says they will use a fluorescent type of light in a lay in fixture that goes into an acoustical ceiling. "To save energy, we put the electric switches on a motion detector," he says. "When someone is in the room there is a sensor that can tell someone is there and the light stays on. When they leave, the light goes off." Deciding on the Dcor A patient feels the most vulnerable in an exam room. Anxiety and insecurity can be compounded by the room's aesthetics. (Listen to MOT's free webinar on creating soulful medical offices with Thomas Moore, author of Care of the Soul in Medicine). "Does the dcor include pleasant things to look at, from fabrics and wall art, to medical information that may be of interest?" says Lerman. "Is the room temperature adequate? Is there a private place to undress? Is the process set up to decrease a patient's waiting time? All these things, and more, help create a positive exam room experience." For your seating area, many experts recommend using vinyl for all seating, but there are a number of fabrics that now resist stains and germs. Technology integration Edmundson says the type of technology you use is another factor to consider. Are your physicians accessing medical records from a computer in the exam room? Do they have tablets? Are they using paper-based records? She says that these considerations will influence how much space you need in certain areas. Proper storage The casework or millwork in the exam room typically provides the most concentrated area for storage-often with room for overhead storage, as well as storage areas below the work surface. Exam tables can also have storage drawers, making them even more efficient. "The benefits of opting for modular casework within exam rooms include future flexibility, especially during moves and changes within your facility; extended warranties and accelerated depreciation," says Edmundson. When looking at exam room furniture, select materials and finishes that help inhibit the spread of bacteria and also promote long-term durability. "In addition, rounded corners on any casework or millwork will help prevent injuries," Edmundson says. Best practices to follow One of the best practices from a general contractor stand-point is to have buy-in from the medical staff that will be using the facility. "Where do they want millwork? Is their practice paper-free, if so space needs to be made for lap-top computers," says Chapman. "If not, allotment for a writing space area must be found. While we know we can never predict the future, we understand the need to create spaces that enable flexibility, anticipates growth and change over time."

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 Lerman agrees that consultation with the physicians and medical staff is a good practice to follow. "I always sit down with members of the practice and ask questions," he says. "I also show them different options for the exam room, such as where the cabinetry can go and the way the door swings into the room-this is critical because it takes up space. I point out the pluses and minuses of each scheme. They know what has worked for them and what hasn't based on their specialty." Whether you are renovating or building from scratch, Chapman says that cheap isn't the way to go when it comes to building or renovating a medical exam room. "Medical practices are going to be around for years," he says. "Thirty years is the average time for most of these types of facilities to come up for renovation. Removing necessities like power or air will end up costing a practice in the end. Ultimately, if all the right elements are planned for at the beginning of the building process it will be a win-win for the practice as a whole."

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Article 5: Efficient Office Design for a Successful Practice

Establishing a practice is a challenge in today's health care market. To survive in this competitive environment, you need to create the best possible setting for you, your staff and your patients. This includes not only architecture and aesthetics, but also technology and furnishings. All of these can affect your efficiency and workflow, which will have a significant impact on your overall productivity. These factors can also affect how comfortable patients feel in your practice, which could influence how likely they are to return to you for future care. This article will explain how design elements can optimize efficiency and patient care. Some suggestions are more applicable to those starting from scratch or making large-scale changes, but even if construction isn't on your agenda, these tips can help you improve your current setup. First impressions count Patients will form their first impression of your office when they enter the waiting room. The current design trend for medical practices is to create a waiting room with an inviting atmosphere similar to a hotel lobby. The optimal size for a waiting room depends on a few factors, including the number of physicians in the practice, visit volume and the overall efficiency of your practice. For example, if you perform many procedures or other services that tend to produce longer visits, you may not have as many patients cycling through the waiting room and may not need as much space. However, if more patients cycle through the office in shorter time intervals, you will likely need a larger waiting room because you will have more patients waiting at one time. If you're unsure how much space you need for your waiting room, consult with an architectural and design firm that understands the mechanics of patient flow and office efficiency. Your patients' comfort should be your priority when you design your waiting room. The seating capacity must be ample, but be careful not to overcrowd your space. The area should provide coat hangers and storage for umbrellas and hats. If your patients typically wait more than a few minutes before being called into the exam room, provide up-to-date educational or entertaining reading material. When selecting furniture, choose individual chairs. Patients tend to be reluctant to share a couch, so couches can waste valuable sitting room. Be sure to purchase some armless chairs to accommodate pregnant, obese or disabled patients. Your furniture should be durable hotel grade, if possible. Select fabrics create a glare. However, many designers advise using incandescent lighting in waiting areas because it is inviting and provides a more hospitable feel. Whatever kind of lighting you choose, make sure the waiting room is well lit for safety and for comfortable reading. that will be comfortable for patients while complementing the decor of the room. The decor in your waiting room should be soothing. Because decor is subjective and styles change from year to year, think twice before following the latest style. Choose colors that are cheerful, natural and inviting. Paints or wallpaper prints with warmer tones are good choices. Also, keep in mind sound absorption when choosing accessories for the waiting room. Carpets, drapes, upholstered furniture and acoustic ceiling tiles can all maximize sound absorption for a quieter room. The lighting in the waiting room also has a considerable impact on the look and feel of a practice. Fluorescent ceiling lights distribute an even level of lighting throughout a room, and they are ideal for basic utility and patient safety, especially for the visually impaired. As long as you have diffusers over fluorescent lights, they shouldn't create a glare. However, many designers advise using incandescent lighting in waiting areas because it is inviting and provides a more hospitable feel. Whatever kind of lighting you choose, make sure the waiting room is well lit for safety and for comfortable reading. How much exam room space do you need? When deciding how many exam rooms your practice needs, consider the types of visits you typically have and both the number and types of procedures you perform most often. An inadequate number of rooms can result in inefficient patient flow and less-than-optimal productivity. Too many rooms will result in wasted overhead.

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 The typical family physician requires three exam rooms and one procedure room, but this can vary in multiphysician or multispecialty practices depending on the number and types of procedures performed. Physicians can easily share a procedure room if they do not perform a large number of procedures. When designing an exam room, begin with a little more space than you initially need to allow for the addition of technology later. The optimal size for an exam room is 10 feet by 10 feet, although these dimensions can vary slightly without affecting the function of the room. Each room should have enough space to comfortably accommodate you, a nurse or assistant, your patient and at least one family member. Think of wheelchair accessibility, too. Smaller exam rooms 8 feet by 8 feet, for instance make it difficult for wheelchair users to navigate in the room. It's good to have space for a 60-inch diameter wheelchair turn, per the Americans with Disabilities Act (ADA) guidelines. In addition to exam rooms, consider having a smaller, separate room where a nurse can measure vital signs, height and weight before the actual exam. This is especially helpful during busy times and can decrease the amount of time patients have to spend in the exam room. Be sure this room provides sufficient privacy for the patient. It will need to have an area where the patient can lie down or sit down so the nurse can take blood pressure or collect other diagnostic information using an electrocardiograph, spirometer or Holter monitor. Having such a room can also make it more feasible to use PC-based diagnostic devices for obtaining vital signs and other data. These are particularly useful if you have or are considering purchasing an electronic health record (EHR) system. Many of these devices now integrate patient data with the patient's electronic record, eliminating the need to import this data through a secondary interface, thereby improving efficiency and reducing transcription errors. The ideal exam room The design of an exam room is important no matter how many rooms you have or how big they are. Because privacy is paramount, make sure the door opens into the exam room rather than into the hallway and is hinged in such a way as to swing toward the exam table. This will shield the patient on the exam table from the view of those outside the room. The ADA requires that the door be positioned approximately 18 inches from the corner, but these requirements could vary from region to region. (See the diagrams for a sample floor plan of an exam room.) The layout of the room should be flexible to meet changing needs, but all the exam rooms in the practice should be designed and stocked identically so that you and your staff do not waste time searching for supplies. The placement of cabinets, sink, chairs, desk, exam table, lights and waste receptacles is critical for ensuring that patient visits run smoothly. Consider how the quality, design and location of each of the following exam room elements can affect the patient visit: The exam table. A wide variety of exam tables are available depending on your budget, the procedures you perform and your patient population. Because your patients will likely spend the majority of their time in the exam room on the exam table, make sure it is comfortable and easy to adjust. For example, a table that can lower to 18 inches from the floor makes it easy for pregnant, post-op or disabled patients to get onto the table without putting excess strain on themselves, you or your staff. These barrier-free tables also decrease your chance of back injury from lifting patients onto the table and from bending over during exams. Some exam tables are fully motorized, allowing you to adjust the height, foot and back sections, and they can tilt to achieve the Trendelenburg position. You can also find tables that feature pelvic tilt, removable tops, electrical receptacle, built-in pillow and positioning programmability. (See Exam room furniture manufacturers and What about used medical equipment? for information on vendors and products.) To facilitate access to both sides of the patient, consider positioning the exam table at an angle in the room. Not only will this give you full access to the patient, but it also will create a barrier to deter the abuse of diagnostic devices that can occur when patients are left unattended and within arms reach of items mounted on the wall.

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Seating. Your stool should be comfortable while also providing support for your back. You can find adjustable stools with an airlift feature that provides some shock absorbency to prevent jolting your spine when you sit down. Its a good idea to have two side chairs for your patients relatives or caregivers. You might consider a third chair if you have an EHR at a drop-down desk away from the exam table. Lighting. The kinds of procedures and exams you perform will dictate the type of lighting you need. Lighting should provide precise positioning with shadow control and proper intensity. Lights are available on caster bases or they can be mounted in a variety of ways. Halogen exam lights can be more expensive than incandescent lights and can get very hot in operation, but they use bulbs that last longer and are more energy efficient than incandescent bulbs. Cabinetry. Consider using 18-inch-deep cabinetry to provide storage while maintaining as much floor space as possible. (For comparison, normal kitchen cabinets are 24 inches deep.) Modular cabinetry is preferable because it allows you to choose the right amount of storage space for your needs, eliminating trips outside the exam room for equipment and supplies. It can also make it easier to take your cabinets with you if the practice moves. The cabinetry should be durable, easy to clean both inside and out, and made with medical-grade materials. Cabinetry designed specifically for health care facilities uses steel and plastics to provide added durability. You can also choose from a variety of colors to coordinate with the paint or artwork in the room. Diagnostic systems. Most offices use a diagnostic system that includes basic instruments needed for physical diagnoses, such as an otoscope, ophthalmoscope, ear speculum dispenser, sphygmomanometer and thermometer. Its convenient to mount these systems on the wall for easy access. If you mount the systems in the same place in each exam room, you and your staff wont need to adjust your routine each time you go into a different room. EHR. Desktop computers are still more popular than laptops for practices that use EHRs. They are best positioned on a desk-height extension of the counter, away from the sink. If you use a tablet computer, consider placing it on a shelf nearest to the point of care or on a rolling stand for greater mobility and to ensure the necessary eye contact with the patient. Dressing area. If your practice requires a dressing area in the exam room, some options include cloth curtains, partitions on wheels or even double-door dressing cubicles that mount to the wall. A dressing area will provide a little extra privacy in case you or a staff member enters the exam room unexpectedly. Waste receptacles. The waste receptacle should have a foot-operated lid and be seamless so that it can retain waste within the can itself. Place it under the wall-mounted diagnostic devices where it is not in the way during the exam but is still easily accessible.

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Article 6: Planning and Designing Highly Functional Nurses Stations

The nurses' station is the fulcrum of activity on the inpatient hospital floor. At some point, virtually every hospital function intersects at this critical junction, often simultaneously, via impromptu meetings among a wide cross-section of hospital staff. This intensive and varied use presents a set of complex and challenging issues for hospitals and the people that help them effectively plan for new or renovated facilities. Over the past three years, members of our current Nurture by Steelcase team have conducted detailed ethnographic research at leading health facilities to evaluate a wide variety of nurses' station interactionsespecially how caregivers perform their duties and how patients receive their care. Nurture's research and design approach is built around the user experience. We undertake five steps to provide specific solutions to our healthcare clients: Understand, Observe, Synthesize, Realize, and Pilot/Test. After analyzing the issuethrough business concerns, technology trends, and what's new and how it affects the organizationNurture's research team goes on-site to build a first-hand understanding of the user's day-to-day work life. The Nurture design research teamconsisting of researchers, designers, and product specialiststhen synthesizes these findings into design principles, criteria, and concepts that feed into the product development process. Finally, Nurture shares all of this information with architects, designers, and clients. Building on existing research on nurses' stations, our research process has allowed Nurture to more fully understand the nurses' station and to come up with what we believe to be better design concepts. Controlled Chaos Many kinds of work happen in the nurses' station, but traditional designs try to force-fit them into a single, rigid configurationtypically with a fortress-like counter and an enclosed room behind it. This assumes that work happens in neat, defined silos. In reality, there's chaos and crowding, with many different behaviors colliding in the space. First and foremost, nurses' stations need to be considered in the context of providing patient care and as a functional work space. Sharp aesthetics are nice, but this space, maybe more than any other in the hospital environment, needs to be highly functional. Through our observations, we have seen examples of different types of nursing station organizational models: centralized, decentralized, and various combinations of the two. Each has its own set of benefits and tradeoffs relative to patient care and work. Centralized. In this model (figure 1), the nurses' station is a central hub on the unitall workstations are located here, as are the unit assistant and most office machines. Pros: Nurses and clinical staff work together in a central location; quick access to peers paves the way for learning, mentoring, and efficient communication; resources can be consolidated. Cons: Less proximity to patients; increased congestion and noise. Decentralized. There is no central hub in this model (figure 2). Nursing stations are located throughout the unit outside each patient room, and the unit assistant is typically located near the entrance to the unit. Pros: Nurses are closer to patients; possibly fewer distractions; each nurse has his or her own work space. Cons: Fewer opportunities for informal learning with peers; sense of isolation; less proximity to control center for the unit assistant. Key Design Principles Regardless of which organizational type one chooses, our research team has identified five key principles to consider when designing a nurses station or series of stations. 1. Allow for Control and Flexibility. The ability for staff and patients to control their environment is crucial. The environment needs to support: changes in care delivery, such as bedside charting and physician order entry; changes in technology, such as increased access to computers (e.g. mobile carts, bedside terminals) and the

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 integration of clinical technology with patient records; and the ability to adapt spaces as needs change. 2. Support the Social Ecology. Social interaction is key to learning. The environment needs to support the many ways people interact for learning. The space should: accommodate generational mentoring and apprenticeship; allow for different group sizes (e.g.,one-to-one and one-to-many); allow for informal versus formal instruction; and allow for on-the-go versus stationary instruction. 3. Understand Work Processes. The environment needs to consider and support the users and activities. The space should accommodate: different types of hospital units; different roles (e.g., physicians, nurses, radiologists); and different types of work (e.g., charting, group rounds, medication preparation and delivery, and shift changes. 4. Reduce Cognitive Load. Information overload leads to confusion and disorganization. The environment needs to support the display of: information that needs to be visible for a long time; information that changes frequently; and ways to call attention to important information (e.g., allergy alerts on a chart). 5. Maximize Spatial Relationships. Space plays an important role in security, staff and patient safety, communication, and physical demands on caregivers. Designers should strive to: understand the relationships between different activity zones to prioritize adjacencies; consider patient monitoring and staff communication when creating sight lines between zones; and consider travel distances when designing (e.g., supply rooms, med rooms, patient rooms, and staff respite areas). Principles in Practice In the centralized model, the length of time and level of concentration required to complete a task led to the development of three distinct zones within the central nursing hub: curbside, step-in, and immersive space (figure 3). Curbside is where impromptu meetings take placequick consultations, chart reviews, etc. This doesnt require a desk or meeting room and is best served by a standing-height work surface that two or more can gather around easily. This type of space is even more important when groups work and roam the floor, such as during physician rounds. Step-in is for more involved work such as charting, dictation, or going over a treatment plan. Seated-height tools are beneficial here, possibly with some medium-height panels to provide some visual or acoustic privacy. Immersive space allows for concentration and privacy for planned meetings or work where participants not only need to fully immerse themselves in the work, but also have access to tools like computers, whiteboards, or other information displays. The incorporation of and careful colocation of these zones allow work to flow more smoothly, supporting all five design principles. To maximize spatial relationships, support control and flexibility, and enhance the work process, the removal of barrier walls in the nurses station helps create an open environment that enhances staff communication and improves traffic flow.

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 To support the social ecology and work processes while allowing for maximum control and flexibility, it is important to incorporate different types of workstations in support of different work activities, (i.e., sitting versus standing, groups versus individual, private versus shared). In the decentralized model, locating nurses' stations just outside the patient rooms allows nurses a clear view into the room, enabling them to closely monitor patient activity. This maximizes spatial relationships, reduces cognitive load, and supports work processes. Because nurses frequently work together, decentralized stations need to be large enough for more than one nurse to work at a time. This supports both social ecology and work processes. Technology can enable real-time updating of information at satellite nurses' stations, reducing cognitive load and enhancing work processes (figure 4). It is also important to plan space for parking and charging mobile computing devices. Best of Both Worlds A combination of both organizational models provides a variety of options and may give users the best of both worlds. For example, nurses stations could be distributed around a central core, which contains the supply and storage areas and meeting rooms. Better nurses station planning and design can help reduce staff stress and fatigue, increase effectiveness in delivering care, improve patient safety, reduce patient and family stress, and ultimately improve outcomes and overall healthcare quality. HD

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Article 7: Nurse Station Design

The design of a nurse station must accommodate the many different types of interaction and work that occur; it is an environment that needs to enhance collaboration, support intensive focus and allow for impromptu conversation. Centralized vs. Decentralized Nurse Stations A centralized nurse station is the central hub of the Unit. In most cases, all workstations, the unit assistant and most support equipment are located here. Pros: Nurses and clinical staff work together in a central location. Quick access to peers paves the way for learning, mentoring and efficient communication. Resources can be consolidated. Cons: Less proximity and visibility to the majority of patients, increased congestion and noise. A decentralized nurse station has no central hub. Nurse stations are located throughout the unit, outside each patient room and the unit assistant is typically located near the entrance to the unit. Pros: Nurses are closer to patients, there tend to be fewer distractions and each nurse has his or her own work space. Cons: There is a sense of isolation for nurses, which lessens opportunities for staff mentoring, support and informal interaction. In some cases, there are opportunities for a hybrid configuration that offers individual work stations between rooms while also providing a centralized hub. The sub-stations allow for focused work effort and support patient viewing (and satisfaction), while the central nurse station (or stations) provides the interactive work environment that supports collaboration and mentorship. Key Design Principles Regardless of which organizational type, there are five key principles to consider when designing a nurse station or series of stations: 1. Allow for Control and Flexibility It is important for staff to feel comfortable and in control in their environment (as it is for the patients). Different situations and preferences require a level of flexibility to the work place to account for the various types of workflow. 2. Understand Work Processes The environment needs to consider and support the activities of the users. The space should accommodate multiple roles (e.g., physicians, nurses, radiologists) and different types of work (e.g., charting, group rounds, medication preparation and delivery and shift changes). 3. Maximize Adjacencies Space plays an important role in security, staff and patient safety, communication and physical demands on caregivers. Designers must strive to understand the relationships between different activity zones to prioritize adjacencies and configurations. Understanding the distribution of medication, food, supplies and information all contribute to the arrangement of spaces. 4. Support Collaboration The nurse station needs to support the many ways people interact for learning and accommodate generational mentoring and apprenticeship as well as allow for different group sizes (e.g., one-to-one and one-to-many). More and more, the delivery of healthcare is integrated and collaborative the standard nurse station of yesterday no longer supports this type of interaction. 5. Reduce Cognitive Load Information overload leads to confusion, fatigue and disorganization. The nurse station environment needs to support many different types of information exchange, but must do so strategically: Maintaining patient privacy, planning for a reduction of noise and clutter, appropriate lighting levels and a variation of physical and acoustic characteristics all contribute to reduced info-overload. Control Centers The nurse station is the fulcrum of activity on the inpatient hospital floor. At some point, virtually every hospital function intersects at this critical junction, often simultaneously, with various meetings occurring among a wide cross-section of hospital staff. This intensive and varied use presents a set of complex and challenging issues for

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hospitals and the people that help them effectively plan for new or renovated facilities. First and foremost, nurse stations need to be considered in the context of providing patient care and as a functional work space. Clean, beautiful aesthetics contribute to the healing environment, but this space, maybe more than any other in the hospital environment, needs to be highly functional. Better nurse station planning and design can reduce staff stress and fatigue, increase effectiveness in delivering care, improve patient safety, reduce patient and family stress and ultimately improve outcomes and overall healthcare delivery quality.

Article 8: Means of Egress

From the reading on Blackboard on page 20-30 of the document

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