Years ago there were two worlds of outpatient care—what physicians provided in their office and what hospitals offered within a defined facility with limited outpatient services. There were a few exceptions to this model, but outpatient care was usually the add-on to already stressed inpatient departments. Little thought was given to convenience, cost control, or amenities. Now, the proportion of care delivered outside the hospital has grown and the demand for special ambulatory environments drives the healthcare market.

Delivery of ambulatory services takes on greater significance as care has shifted from the inpatient to outpatient setting, and more hospitals consider expanding or building large ambulatory care networks and facilities. With increased capital investment and the complexities of staffing and operations, the strategic costs of not getting it right are risky. Compound all of this by potential changes in financial structure, accessibility, and care delivery oversight, and planning becomes even more daunting.

It is no longer enough to just build space and shift services out of the hospital and hope for success. The future of “American” healthcare as a hospital-centered system for care is rapidly being challenged by a new model focused on prevention, healing, and chronic care delivered in the lowest cost/highest access setting—ambulatory care.

What does this mean for healthcare institutions and those who consult and design for them? How is this different for pediatric institutions compared to adult care? In our recent survey, hospital leaders revealed common issues surrounding ambulatory care that “keep them up at night.” The top response was lower reimbursement.

Other major concerns were:

• Access;
• Facility capacity;
• Coping with technology;
• EMR/IT connectivity;
• Enough staff/providers;
• Managing complexity; and
• Customer service/expectations.

Future trends
Although the future is murky, there are trends illuminating potential realities. Physicians shifting from private to institution-partnered practice are becoming a groundswell. The complexity of managing business, lower reimbursement, and proposed accountable care organizations are driving physicians into large group practices or partnerships with hospitals. Unlike the physician practice buying rush in the 1990s, partnerships being created today are based on services integration and incentives alignment.

These same factors are fueling integration of primary and specialty care networks to manage complex disease entities and focus on constituents’ health. This means different types of facilities will be needed to support the new models. Simultaneously, there will be more centralization of services into larger buildings and decentralization into neighborhood settings.

The financial pressure on care delivery increases with capitated care, services bundling, medical homes, and access expanded for millions of currently uninsured patients. Technological and clinical practice changes accelerating the shift from inpatient environments to less costly outpatient settings require a new business model to understand a refined pricing model and, in some cases, will require building code changes. For example, in pediatrics where sedation is frequently used to reduce anxiety or keep a restless small child immobile during a simple procedure or MRI scan, some state codes require an operating room environment whenever a moderate anesthetic is used. This forces more expensive construction for noninvasive tests.

There will be increased pressure on information technology to expand to meet greater demands for integration of patient information across all settings, access to systems by patients, and new uses of IT, such as home monitoring, telemedicine, and virtual visits. This is changing how care providers interface with each other and the patient. Data-driven performance measures will be required and fuel the need to incorporate performance improvement tools, such as Lean/Six Sigma, into all aspects of the care delivery process and the facilities designed to support outpatient care.

Program evaluation
The magnitude and rapidity of change may appear overwhelming at times; however, there are some proven techniques that can make the future more manageable. The first priority is for institutions to examine their current state. Basic tools can be utilized to perform a program evaluation. Benchmarking, service analysis, process flow maps, simulation modeling, and satisfaction surveys all serve as a strategic lens to review an ambulatory program with clarity. Tracking and understanding room use throughputs is a critical start. Typically, these are lower in pediatrics than adult care.

Time studies are an important internal benchmarking tool to identify best practices within existing clinics that can be adopted as system-wide standards. With time study information, development of actual and ideal process flow maps, such as the checkout process example below, can elicit issues that are causing delays or bottlenecks in patient throughput. This process informs planning for space requirements and most efficient use of space.

Simulation modeling is an invaluable tool, both for pinpointing issues that may not be recognized intuitively and to test alternative solutions. Prior to investing in costly staffing or facility changes, a simulation model can study a proposed operational or plan change without risk and allow examination of impact. Evaluating several different initiatives with a model provides concrete data on which combination results in greater efficiency and optimized patient experiences.

Communication is always a key to success. Satisfaction surveys and focus groups provide a greater understanding of the actual desires and needs of patients, families, physicians, staff, and communities. Information gathered helps us to include amenities that drive family satisfaction, such as changing tables for large children in bathrooms or discrete areas for nursing mothers, and better align budgets by including spaces of greatest value.

Careful appraisal and study of an ambulatory program can only be accomplished by utilizing a combination of the tools discussed above. For the evaluation to reach its full potential, all stakeholders must be well-versed in the results and participate in the ongoing process of continuous performance improvement. According to Elizabeth Woodcock, an expert on physician practice management, “The ‘that’s the way we’ve always done it’ factor is the most common and most dangerous of all variables in patient flow.”

Facility response
As we look at future trends and evaluate the state of ambulatory programs, a key question is how do these factors influence facilities? Seven core considerations must be taken into account as we design environments:

• Patient/family-centered care;
• Safety;
• Quality;
• Flexibility;
• Efficiency;
• Staff support; and
• Technology.

Patient and family-centered care have received a great deal of attention in the inpatient setting, but both deserve greater inspection in the outpatient environment. Lessons learned from the rush to create settings that grow ever larger and elaborate to outdo competitors should be applied to avoid unnecessarily super-sizing facilities. Ambulatory amenities should be based on active communication with families and staff regarding real needs versus things that would be “nice to have.” The most commonly expressed desire by families is to quickly and easily complete their visit.

Safety lessons from inpatient care that apply across outpatient environments to eradicate errors include s
tandardized, same-handed exam rooms, and Lean processes. Security and badging are challenges that must be addressed in the outpatient environment, particularly in the pediatric setting. With the proliferation of more procedures transitioning to the outpatient setting, calming positive distractions should be incorporated into procedure suites to reduce sedation needs.

Maintaining quality as institutions move their trusted brands into the community is a given. The patient experience must remain consistent, but with thoughtful planning, more economical designs can be achieved in satellites and neighborhood clinics.

Flexibility is enhanced with an open floor plate locating stairs, elevators, mechanical, and support functions at floor ends. Module and room design standardization allows clinics to grow in place without renovations and allows space to be used by different programs on different days, enhancing space utilization efficiency.

This is particularly important in pediatrics given the number of low volume specialty clinics and can help shift throughput volumes to the higher end ranges. Simulation modeling also reveals that if patients or staff must walk more than 250 to 300 feet horizontally, it is faster to travel vertically in buildings with appropriately designed elevator systems. This information can influence key adjacencies in a scientific rather than emotional manner.

As institutions face increased outpatient care, they will confront qualified staff shortages. Physician specialists, especially the subspecialist pediatricians, mid-level providers, nurses, and technicians all are expected to be in short supply. To recruit and retain the best, institutions must create space that supports staff. Access to natural light, lounges, and adequate work space are desired amenities, and in turn, competitive recruitment tools. In ambulatory, the amount of work area in proportion to exam rooms has been increasing with computerization and larger, collaborative care teams.

The real future differentiator is technological innovation. The EMR initially reduces ambulatory throughput and impacts exam room layouts as providers seek to minimize the barrier computer use creates to patient/provider interaction. The real game changing nature of technology will further drive design as touch interfaces, self-measuring devices, virtual examinations, gesture technology, and augmented reality transform how care is provided in the near future.

Preparing for an uncertain but radically different future begins by recognizing our clients’ needs are rapidly changing. While institutions must evaluate their programs and understand where they are, develop a culture of change, continuously educate themselves on technological innovations, and seek significant performance improvement, so must we. The mission is critical. We must design operations, facilities, and experiences that:

• Position outpatient care to enhance profitability;
• Maximize flexibility to address volume, market, and care delivery uncertainty;
• Enhance the experience to create brand recognition and customer loyalty;
• Incorporate rapidly emerging technology; and
• Develop new physical environments that support sustaining health. HCD

Diane R. K. Osan, FAIA, ACHA, and Tom Fannin, AIA, ACHA, LEED AP, are senior principals at FKP Architects. Cheryl Stavins, RN, MSN, FACHE, is a senior consultant at FKP Advisors. For more information, e-mail