Research Weighs Effects Of Healthcare Workspaces On Team-based Care
U.S. healthcare systems are moving away from episodic care delivered in silos to coordinated, team-based care that improves population health. One model, the patient-centered medical home (PCMH), is supported by the National Committee for Quality Assurance (NCQA), though other groups and systems are creating similar systems with the goal of providing:
- Comprehensive primary care that helps patients stay well and manage chronic disease
- Care that develops long-term relationships with patients rather than focuses on transactional medicine made up of individual clinical encounter
- Proactive population health management instead of reactive individual care
- Care by a multidisciplinary team that includes physicians, care coordinators, nurses, medical assistants, pharmacists, behavioral health specialists, dieticians, and others
- Coordinated care by high-performing teams that allows team members to contribute at the highest level of their own expertise and communicate effectively through electronic medical records and face-to-face communication.
This kind of proactive, team-based model helps to reduce cost, improve outcomes, and improve patient experience.
The NCQA has formalized these goals and established a set of standards and a recognition program for PCMHs. The model includes principles of improved quality and safety, enhanced access to care, coordinated care, and payment models that reward improved outcomes.
Although necessary to the PCMH model, the move from physician-centered practices to practices where a physician leads a care team is proving particularly challenging, largely because the healthcare industry today has well-established roles and hierarchies and is reluctant to change.
To answer the trend of physicians shifting from independent practices to salaried employees of larger healthcare systems, the built environment is evolving, particularly by moving doctors out of private offices and into more open workspaces as a foundation for changing processes and opening lines of communication and collaboration, which are essential to this approach to care.
While open workspaces are recommended to create a PCMH, considerable literature since the 1970s shows that using that model in traditional office settings can actually decrease communication and interaction if not properly designed. Designers should consider the tasks, culture, and technology of an organization to effectively impact communication.
A research team composed of senior researcher Jennifer DuBose and PhD graduate student Lisa Lim from the Georgia Institute of Technology, as well as researcher Doug Bazuin and Ross Westlake of Applied Knowledge and Insights from Herman Miller Healthcare, was interested in the evolution of team-based care and the ability of the built environment to facilitate or impede it. The team developed a research program to explore design solutions for care team rooms. The project was selected by the Academy of Architecture for Health Foundation (AAHF, part of the American Institute of Architects) for the foundation’s 2014 annual research grant.
The research team reviewed articles from various domains to identify implications for team room design. It was found that while a variety of communication studies had been conducted, particularly in office settings, only a few articles addressed workspace features that support communication among healthcare teams and there were no specific studies of settings for multidisciplinary care teams in outpatient settings. The lack of literature specific to PCMH-style team room design emphasizes the importance of this project for the rapidly emerging outpatient model.
Building from the literature and clinic observations, a framework and model were developed for designing and evaluating the psychosocial characteristics of outpatient team spaces and their impact on collaboration and clinical work processes. The team identified four areas significantly impacted by design: culture, communication, individual work, and coordination and awareness.
Additionally, specific dimensions of the environment were broken down into those affecting workplace communication and collaboration: proximity, visibility, artifacts, connectivity, openness, and arrangement. Each of these dimensions describes an aspect of the staff, their work, and their relation to each other and elements of their physical environment.
While the team learned from the literature review, much more was learned by going out into the field to observe how teams work in different spaces and conduct interviews with key staff members in PCMH-certified clinics.
A common practice in outpatient clinics is to design a division between onstage spaces where the patient travels and offstage spaces where staff can work without patients being present. The 53,000-square-foot, two-story Group Health Puyallup Medical Center in Puyallup, Wash., integrates laboratory, imaging, pharmacy, and other outpatient services with family medicine, pediatrics, and obstetrics. It uses three clinical pods, with typically five to six doctors per pod, and can serve up to 30,000 patients in total.
The clinic achieves an onstage/offstage division with separate corridors for patients and double-door exam rooms with patients entering from one side and staff from the other. The majority of patients self-room. In this design, the team room is isolated acoustically from the onstage areas, permitting greater openness of staff communication without concerns of patients overhearing.
On the other end of the spectrum, the team room at the Emory Healthcare Patient-Centered Primary Care Clinic, a three-provider practice serving Emory Healthcare employees, is completely accessible to patients—in fact, patients enter the clinic via the team room to access the exam rooms. This has the advantage of making the patients highly aware that an entire team is responsible for their care, not just an individual doctor.
Additionally, it gives patients and staff multiple opportunities to interact beyond the exam room. This accessibility and symbolism does come at the cost of dampening verbal communication between clinical staff about patients to protect confidentiality.
A wide range of physician compromises and spaces were observed, from partially enclosed to fully open spaces. For example, at the Emory clinic, there’s a shared doctors’ office that’s adjacent to the team room where doctors can work while still being visible and accessible to the rest of the team.
At Group Health, the facility also initially used separate but adjacent physician workspaces; however, after operating for a period of time, most perceived the benefits of being in close proximity and collaboration with colleagues and began working in the team room space.
A key strategy for success of a shared team room was creating a positive draw for all—a place that’s not only attractive but also is a point of intersection and activity. Other observations noted that the configuration and arrangement of the team room affected communication and collaboration.
For example, two different outpatient clinic spaces operating out of the Cherokee Indian Hospital in Cherokee, N.C., are very similar in overall size and layout but had very different team room configurations, causing variances in staff visibility, orientation, and even elevation (seated or perch
ing) when the staff worked. Communication patterns both among and across teams were very different between these two rooms. And while further research is warranted to evaluate more closely the impact of these factors on communication behaviors, it was clear that just being close to one another doesn’t guarantee communication or collaboration in a team room.
Research on clinicians, specifically, found that most nursing tasks in team rooms are short—typically two minutes or less. In fact, caregivers were often observed standing, bent over a seated-height work surface, because they had only a brief task to complete and were reluctant to take the time to sit. Yet most team workrooms are predominantly made up of seated workstations.
Additionally, perching workstations appeared to increase not just situational awareness but also unplanned casual interactions. Further, different staff roles require different ratios of collaborative and heads-down work: Physicians typically require a greater proportion of heads-down work than medical assistants, for example. This creates a more complex picture in designing the ideal team room.
Two things appear clear: The key is creating the right mix and the right configuration of spaces based on the culture, communication, work, and collaboration that needs to occur, and, as the model evolves, creating an adaptive team room that can flex with inevitable changes.
This research continues, focusing on team room behaviors and configurations as well as the tools and methods to help healthcare organizations and architects determine the right mix and layout for specific situations.
Jennifer R. DuBose is the associate director of the SimTigrate Design Lab and a senior research associate with the College of Architecture at Georgia Tech (Atlanta). She can be reached at firstname.lastname@example.org. Ross Westlake is a member of the Herman Miller Healthcare Knowledge and Insights team. He can be reached at email@example.com.