Healthcare is moving away from individual encounters with single clinicians and toward coordinated, integrated care by high-performing teams. This is particularly true in the outpatient environment and for healthcare systems pursuing patient-centered medical home (PCMH) models of care.

A research team composed of senior researcher Jennifer DuBose, PhD graduate student Lisa Lim from the Georgia Institute of Technology, and Ross Westlake of Applied Knowledge and Insights from Herman Miller Healthcare explored the ability of the outpatient clinic’s physical environment to facilitate or impede collaboration and communication in PCMH care models.

Environmental influences on collaboration were found to vary across scale and can be categorized into three levels: the clinic level, the team room level, and the workstation level. Aspects such as overall typologies and configurations drive collaboration on a clinic level; however, the research reveals that smaller design elements in the team room and workstation levels are also significant influencers.

An opportunity arose to deepen the research as well as apply and test the learnings at Mercy Care, a federally qualified health center in Atlanta and a PCMH clinic recognized at the highest level by the National Committee for Quality Assurance. Mercy Care was in the process of renovating its clinician work areas and asked for assistance in redesigning these spaces.

To understand the needs and work styles at Mercy Care, field observations were conducted of the Mercy teams in action. Researchers shadowed providers and documented behavior through timed rounds, recording the activities occurring at key staff work areas and transit locations around the clinic. Using electronic tablets, the team recorded the time, location, activity, communication partners, and items used by each person observed during shadowing and behavior mapping.

The clinic, as it was laid out at the time of the research, had separate workspaces for physicians/nurse practitioners and medical assistants—and they weren’t close, let alone adjacent. Analysis of the behavioral data points from the observation confirmed what was suspected: The groups of clinicians communicated 45-65 percent less with staff members who weren’t peers and who weren’t closely located than with their peers in their common workspace.

This strongly reinforced the hypothesis that traditional clinic staff layouts don’t support inter-professional collaboration and communication, which are both critical for new, integrated care process models.

Understanding needs
As reported previously in the April 2015 Research column in Healthcare Design, the researchers identified four ways clinic and team room design might affect the team and its work processes: culture, communication, individual work, and coordination and awareness. Those considerations guided the work with Mercy Care to design a solution that would be best for the provider’s needs. While the Mercy Care renovation didn’t afford the opportunity to change much of the overall clinic configuration and adjacencies, it did allow a new layout for integrated team workspaces.

In speaking with the staff, differences between their explicit and tacit needs were also observed. Explicit needs are often expressed—such as the ability to see exam room entrances or to have a space where a caregiver can concentrate with minimal distraction. Tacit needs are those that caregivers may not be as aware of—such as finding other staff members or having accessibility to others.

Previous literature and research at various clinic sites indicated that communication patterns of similarly functioning teams varied widely in different built environments. The observed differences supported previous research that, in general, sociofugal configurations, which promote seclusion by having the seating facing outward, are less supportive of unplanned communication than sociopetal configurations, which encourage interaction by having the seating facing into a group.

Additionally, the research suggested that while an environment may meet the explicit needs of a team, it won’t necessarily support their tacit needs, including their need for casual, unplanned communication and collaboration.

To facilitate and balance the range of needs, the researchers engaged the staff and involved them in design decisions, particularly to help them better understand their competing needs and make them aware of some critical ones they may not have been able to articulate. Together with Mercy Care, a mock-up and simulation was designed to achieve these objectives and further the research.

Applied research
Based on the research and observations, and after many iterations, two layout options were selected. Both options included a mixture of areas with low or no dividers and sociopetal configurations to provide the staff with sightlines to each other, as well as spaces where height and visibility were restricted to provide the opportunity for focused concentration.

Though both layouts contained each design, the team intentionally crafted clear differences in visibility, height, and staff orientation between the two options. By design, one favored communication and collaboration and the other concentration.

These two options were built at the SimTigrate Design Lab using a combination of actual furniture frames, foam core, paper, and tape on the floor to create a dimensionally accurate mock-up.

Next, with the help of the Mercy Care staff and simulation facilitator Dr. Michael Toedt, a set of clinic scenarios, or mock processes, was created. These scenarios were intentionally designed by Toedt to introduce appropriate variability to the process and invoke situational awareness in general, and collaboration and communication needs in particular.

Another goal was to tease out the needs of individual roles as well as highlight the symbolic implications of how the workspace is configured. Examples include having the doctors and nursing staff work in a shared space, more open work areas that allow staff to see and share information readily, and open and perching-height spaces to facilitate brief, flexible work patterns.

The simulation started with two team space options—giving the clinicians a guided choice—and a plan to discover unmet needs and help the staff become more aware of their tacit processes and needs for collaboration and communication.

In short, a dynamic, expert-driven simulation was created using relatively low-fidelity materials with a high-fidelity approximation of space. The clinical staff from Mercy Care were actively engaged in the simulation exercise and offered modifications to the layouts based on their experience during the simulation. The final version of the team space design incorporated feedback from the staff and combined elements of both options.

The staff was surveyed before and after the simulation. While the small sample size precluded statistical significance overall, numerically the results pointed to strong differences in the staff’s opinions pre- and post-simulation. After the simulation, they responded more strongly to the differences in more open and more restricted workspaces and on average shifted their preference to the layout that facilitated greater communication and collaboration.

The simulation exercise provided the care team an opportunity to experience how they might actually function in
different layouts, and allowed them to have a more informed input into the design selection based on functional performance rather than simply on initial impressions or aesthetics.

By structuring the functional simulations in advance, and in a manner that accurately connected clinical work space with clinical processes, and then offering guided choices about the configured space, the team believes it arrived at an effective design solution more quickly and efficiently than if a more open-ended, less-planned process had been used.

The new caregiver stations have been installed and anecdotal reports from the staff have been very positive. The research team is planning to conduct a set of follow-up observations and post-occupancy evaluation to measure the impact.

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 Ross Westlake is a member of the Herman Miller Healthcare Knowledge and Insights team. He can be reached at