When embarking on a new outpatient clinic project, the University of Wisconsin Medical Foundation (UWMF) zeroed in on design goals of supporting Lean and efficient operations as well as staff collaboration and enhanced patient privacy. The solution was to create an integrated care team (ICT) space as close as possible to the areas where care is delivered. A plan was developed that separated back-of-house ICT space from front-of-house patient amenity areas and circulation. However, when completely separating front-of-house and back-of-house functions in a clinic setting, the one place the two must overlap is in exam rooms.

To answer this challenge, the design concept was to create dual-access exam rooms with patient entry from the public corridor and caregiver entry from the care team collaboration area, maintaining complete autonomy for both realms. Caregivers would be able to collaborate within a significantly more efficient and fully integrated care team environment without concerns for patient privacy or interruptions, and patients would be provided with a comfortable, hospitable environment away from the clinical environment.

Study guide
To see if the approach worked in what today is the Yahara Clinic in Monona, Wis., the design team conducted a post-occupancy evaluation, specifically studying hypotheses related to the project’s goals.

The first hypothesis that informed design was that creating off-stage ICT work areas would maximize staff efficiency and increase patient privacy. Yahara Clinic adopted a patient-centered medical home model of care that required many caregivers to work together to oversee the health needs of their patients.

The ICT work areas locate physicians, medical assistants, nurses, social workers, and other caregivers adjacent to each other to increase collaboration and allow for real-time conversations. These work areas are also adjacent to exam rooms, reducing the distance caregivers travel between workstations and exam rooms. Off-stage work areas reduce the opportunity for patients to overhear conversations about other patients, which increases patient privacy.

The next hypothesis was that utilizing a self-rooming operational model would reduce wait times and increase patient privacy, patient safety, and staff efficiency. Using technology to indicate available exam rooms, patients can be immediately directed to their rooms by a receptionist instead of being seated in a public waiting area. Receptionists use medical records software to alert the caregivers that patients have arrived.

Caregivers receive patients in their exam rooms, where they are privately weighed, which many patients prefer. By not waiting in a centralized waiting area, patients aren’t exposed to other patients who might be contagious, and staff no longer needs to go to the waiting room to retrieve patients. This saves time and steps, allowing for more time spent on patient care.

Under this model, the waiting area was sized to be smaller than typical clinics require since only patients who arrive early or have other people with them would utilize this space. According to the Advisory Board Co.’s presentation “Ambulatory Facility of the Future, Part II, Enhancing Facility Performance through Design Innovation,” the average traditional clinic accounts for 1.5 seats per exam room but cites that an optimal proportion is closer to 0.5 seats per exam room.

In the Yahara Clinic model, there are 0.45 rarely used seats per exam room, indicating the waiting room could have been even smaller. The dual-access exam rooms required two doors and 12 additional square feet per exam room as compared to UWMF’s typical clinic exam room of 108 square feet.

However, the overall building square footage was comparable to a traditional clinic building due to other design efficiencies, including reduced waiting room size and centralized ICT spaces. By providing workstations for the physicians adjacent to the other care team members, the design team was able to eliminate private physician offices in the clinic setting altogether. Private and shared offices were provided on the second floor; however, they’re rarely used. These offices were planned to be flexible clinic space, though, and can easily be converted into exam rooms in the future.  

Putting design to the test
During the planning process for the Yahara Clinic, two existing clinics that were being combined in the new space started implementing the self-rooming process with some of their providers. Both existing clinics were designed with a traditional reception and waiting area, a shared nurses’ station, and exam rooms adjacent to private physician offices. Researchers conducted observations at both of these clinics, where traditional rooming and self-rooming was occurring, utilizing behavioral mapping to track the motions of multiple nurses at both locations.

In the traditional model, the nurses went to the waiting room to retrieve a patient when their computer alerted them that the patient had checked in, then stopped in the corridor to weigh the patient, and proceeded to an available exam room. The nurses rooming patients in this typical process were often observed using a computer in an empty exam room as their temporary workstation, since the nurses’ station was many steps away.

The data collected was modeled using a software tool that visually demonstrates trip frequency and relative travel distance of the clinical staff. The data was inserted into the new facility’s plan to show how this would impact workflow in the new facility.

One year after occupancy, a researcher went back to Yahara Clinic to observe nurses again as they provided patient care and to interview caregivers about the new building. Using facility plans, measurements were compared to calculate average travel distances of nurses. The clinic manager, two physicians, and two nurses were interviewed about the operational changes at the new clinic as compared to their previous environments. Patient satisfaction scores were requested to compare scores in the previous facilities to those of the new one.

By separating front-of-house from back-of-house functions and combining patient self-rooming with dual-access exam rooms and an immediately adjacent ICT space, Yahara Clinic realized an 83 percent reduction in staff footsteps, a dramatically Leaner model than the existing clinics.

The new model also resulted in an overall 25 percent increase in patient satisfaction scores and a 17 percent increase in patient satisfaction in the category of “general reputation, wayfinding, and the environment” (as measured by Avatar Solutions, a performance improvement company specializing in patient satisfaction surveys ). In addition to the positive patient feedback received from patients, caregivers interviewed overwhelmingly commented on the improved working environment, improved patient privacy, increased collaboration between caregivers, reduced interruptions to nurses, and improved efficiency thanks to close proximity of exam rooms.

Overall, designing an ambulatory care environment that supports two newer operational models—patient self-rooming and an off-stage integrated team center with dual-access exam rooms—enhances measures of success, saving time and money while improving the experience for patients, physicians, and staff.


Kate Egan, AIA, EDAC, LEED AP BD+C, is an associate and architect at Kahler Slater and a leader of Kahler Slater&rsqu
o;s environmental design research team. She can be reached at kegan@kahlerslater.com.


SIDEBAR: Green opportunities realized
An additional hypothesis measured through the post-occupancy evaluation at the Yahara Clinic was that achieving LEED certification would save significant long-term operational expenses and improve the staff workplace experience. To that end, the design team researched sustainability opportunities, incorporating the LEED checklist and certification process into the project.

For example, one of the initiatives—providing daylighting—was intended to enhance the work environment and staff’s connection to nature.

The integrated care team spaces and other offices are located along the building’s exterior to provide natural light, while exam rooms and procedure rooms are located toward the interior. The ends of patient corridors have windows with views to nature to provide light and wayfinding cues.  Clerestory windows in patient corridors transfer light into patient spaces.

Additional sustainable features include overhead interior lights on sensors to dim on sunny days and task lights provided at workstations.  Pressure-assisted toilets reduce water consumption.  Preservation and protection of adjoining natural wetlands was achieved by including a detention pond to capture storm water runoff and planting native landscaping.

The project design resulted in a 37 percent reduction in potable water use, a drop in annual energy costs of 14.7 percent, and a contribution to the improved staff experience due to an appreciation of the natural light and views to nature from the working environment.