National University Hospital (NUH) in Singapore began planning in 2009 for their new 775,000-square-foot medical center-home of the new National University Cancer Institute of Singapore project (NCIS) and the Specialty Outpatient Clinics (SOCs). Their mission was to integrate excellent clinical care, translational research, and superior medical instruction to support their vision, “Shaping Medicine for the Future.” Working with Kahler Slater's Singapore office-a Milwaukee-based Evidence-Based Design Accreditation and Certification (EDAC) Champion firm-and a local Singaporean firm, Consultants Incorporated Architects and Planners (CIAP), NUH established a strategy to create a new world-class ambulatory medical center. From the onset, the design's intent was to promote experiences that would allow NUH to accelerate the realization of their vision.

NUH recognized that a major influence on the design would be the educational aspect of the project. Therefore, they employed a strategy to redesign the undergraduate medical school curriculum for teaching and learning in the ambulatory setting. The curriculum is being rewritten to promote more case-based, interactive, hands-on learning with students having assignments to participate in real clinical settings with real patients and senior physicians. Anticipating additional space requirements for students in the clinical setting became a key focus in the design of the SOCs.

With funding from the Robert Wood Johnson Foundation, The Center for Health Design engaged industry experts in 2005 to help define and standardize the evidence-based design (EBD) process and create the EDAC program. The EDAC exam, which launched in April 2009, is designed to educate and train individuals to implement an EBD process in new and existing healthcare environments.

Anyone interested in learning more about EBD-including design professionals, healthcare facility planners, clinicians, researchers, product manufacturers, educators, and students-can study for and take the EDAC exam.

Currently there are more than 300 accredited individuals worldwide. To view the directory, get study resources, or learn more about the exam and those who are supporting the EDAC program, visit

To support its educational goal, NUH wanted to use the latest thinking in evidence-based design (EBD). The design team and researchers understood that an innovative approach was needed and applied evidence-based principals. The following gives a glimpse into how EBD can be applied to the medical education setting.

Establishing research goals and objectives

To gain a better understanding of the design requirements necessitated by the new educational experience in the SOCs, as well as learn about the current facilities and practices, Kahler Slater began with a study using the EDAC process. The study focused on how undergraduate and postgraduate teaching is currently being conducted, and then, based on the findings, identified opportunities for design of the consult room (exam room) that would enhance teaching, learning, and patient care.

Collecting relevant evidence

Benchmarking: To learn more about how other world-class facilities are integrating teaching and learning, representatives from NUH and the design team traveled to benchmark other academic medical centers: Samsung Cancer Center in Seoul, South Korea, Taipei Veteran General Hospital in Taiwan, and the University of Pennsylvania.

Observations: Kahler Slater, working with Conifer Research, conducted a four-week observational research and rapid prototyping mock-up project to more fully understand the existing clinical experiences and environment. Patient and families were informed of the study and consent forms were signed by all patients whose consultations were observed. The first two weeks involved both recorded and direct observations in the existing clinics. The majority of consultations were recorded, using multiple video cameras, aimed away from the patient couch (exam table), and focused on the physicians' desk and the doorways to capture interaction between physicians and students. In some clinics where physicians did not feel comfortable with recording, observations were conducted live. Clinics and consult rooms were photographed and floor plans were analyzed. Interviews were conducted before and after consultations with undergraduate students, postgraduate students, supervising physicians, and nurses.

Two daily clinic sessions were conducted, morning and afternoon. Supervising physicians and postgraduate students were each assigned to a consult room to see patients. Undergraduate students were assigned to the clinic to observe and participate when possible during the consultations. This model is a stark contrast to the United States ambulatory model, as NUH physicians stay in one consult room during their morning or afternoon session, with patients going in and out. When patients arrive and check in, they receive a queue number based on their arrival time. The majority of patients wait in the corridors, outside the consult rooms. Most consult rooms have two (or more) doors-one main door to the corridor for patients to use and then sliding doors to connect the consult rooms. Supporters of this model of care believe it supports higher efficiency and increases opportunities for mentoring.

Interpreting the evidence

Following the benchmarking tours Kahler Slater surveyed the participants to capture individual observations and reactions. The discussions identified common themes and topics for the design team to investigate further. Key observations were made related to learning spaces, including the transition from simulated learning methods to “real world” teaching in the consult rooms with patients. Other observations touched on integration of technology, patient-centered care, connections to nature, and access to daylight.

What is Evidence-Based Design? The Center for Health Design defines evidence-based design as “the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.”

The clinic observations confirmed some initial assumptions and introduced other factors to be considered in the design process. One key observation is the importance of the physician's desk being central to the consultation. The interaction between the patient and care team begins and usually ends here, with the patient moving to the exam couch (table) for the physical exam. When interviewed both the students and the physicians stressed the importance of the student having a place at the desk, “next to me” as one physician described. “Then they can see whatever I am doing, at the same time as me.” The student learns the most by seeing what the physician sees: the patient, the case notes (medical records), and the computer screen. The existing clinic layout does not accommodate a place for the students at the desk. They were often observed sitting on the patient couch, standing off to the side or in doorways as they try to stay out of the way, yet see as much as possible. Sitting at eye level with the patient next to the physician is also important for students. When standing, they sense the patient's discomfort and as one student described, “if we are standing, the patient may feel a bit awkward… it seems that we are not part of the team.”

Another important factor in the consultation room is door placement and usage, as they provide the students and physicians access to each other in the environment where postgraduate students are seeing patients independently. Students and physicians were observed using sliding doors, which are located between consult rooms, therefore avoiding entering the corridor where the next patient is waiting. Easy access to each other was essential, especially when the student had a question for the physician or if the physician wanted to check in on the student. In order to avoid disrupting the examinations, physicians and students would often slide the door open a bit and “peak” into the consult room to observe the situation before opening the door fully. Unfortunately, the location of the connecting doors in the current clinics is close to and aligns with the patient chairs-sometimes causing an awkward moment when the patient can see into the adjacent room. Students and physicians often struggle to move from one room to another since they have to navigate around the patient and family members sitting near the door.

Overall, the existing size and layout of the consultation rooms restricts undergraduate students from fully participating in examinations, inhibiting their learning, and making it difficult for faculty to instruct and observe postgraduate students. Also, the layout provides a less than ideal patient experience. Larger consult rooms are needed in academic medical centers to accommodate additional people compared to the typical ambulatory consult room. Space for the teaching needs to be allocated.

Innovating: The teaching hub

Diagram of existing clinic consult room with participants' usual location identified
Diagram of existing clinic consult room with participants' usual location identified

As mentioned earlier, NUH is updating the curriculum as a means to engage more students into the clinical setting. As a result, additional square footage is being planned in the SOCs. Key to the goal of creating an interactive and integrated clinical education is providing space in the consult rooms to accommodate at least two students, sharing the professional caregiver zone with the senior physician. This allows the student to be seen by the patients and families as a part of the caregiving team. Additionally, this will create a more patient-friendly experience.

From the observations, interviews and analysis, the design team learned that not all teaching and learning can or should occur within the consult room itself. Through the design process, an idea emerged for supplemental teaching space, an embedded teaching hub to provide students and physicians with designated space for discussions away from patients and families. The teaching hub would be adjacent to multiple consult rooms and include appropriate learning technology and materials for short-term research and study.

Rapid prototyping mock-up

To better understand how the consult rooms and adjacent teaching hub would function for the students, physicians, and patients, a full-scale mock-up was built for rapid prototyping so design options could be evaluated thoroughly and quickly. Two consult rooms and an adjoining teaching hub were constructed at the existing hospital and were outfitted with furniture and equipment. Over the course of 10 days, students, physicians, nurses, administration, and other hospital and NUH staff visited the mock-up to experience the design concepts.

The mock-up consult rooms were furnished with a desk, chairs, a sink, computer monitors, and a patient couch, as well as two doors-one to the corridor for patient access (it should be noted that the new medical center's design will no longer require patients to wait in the corridors) and one door connecting it to the teaching hub. The teaching hub will be connected to four consult rooms and access two corridors. For the mock-up, the teaching hub was furnished with workstations, whiteboards, projectors, and other educational equipment. Some groups brought down wheelchairs and special equipment their department uses and tested the space. Participants acting as patients were brought in and out of the doorways on trolleys (stretchers) and furniture was moved to test numerous layout possibilities.

To capture each person's input about the design options, participants completed a written survey during the rapid prototyping activity. Additionally, multiple layouts for the consult rooms were posted and each participant was asked to rate the schemes that seemed to best accommodate the way they practice and teach. Puzzle pieces and plans were also provided to allow participants to consider additional layouts. Participants confirmed the ideal size and proportion of the rooms, as well as the location and type of doors between the consult rooms and the teaching hub. The vast majority of the rapid prototyping exercise participants (93%) believe providing embedded teaching hubs will lead to a higher a quality of teaching and learning.

By following the EDAC process, the design team was able to create the embedded teaching hub concept. Evidence gathered from benchmarking visits, consult room observations, student and physician interviews, and rapid prototyping comments and survey data provided the basis for the overall design decisions. It is expected that the teaching hub innovation will enhance student learning and faculty instruction, while improving the overall patient experience in the SOCs. To confirm this hypothesis, a study will be conducted to capture postoccupancy data at least one-year after the clinics open. The NUH Medical Centre is currently under construction and the first phase is scheduled to be completed by the end of 2012. HD

Kate Taege, MArch, EDAC, is Design Reseracher and Jim Rasche, AIA, ACHA, EDAC, is CEO at Kahler Slater.

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Healthcare Design 2010 May;10(5):70-78