Design for meaningful and efficient patient visits

Optimizing Space in Medical Practices

  • Nicholas Watkins, PhD, EDRA BBH Designs
  • Michelle Gandolf-Frietchen, MA Cleveland Clinic
  • Zishan Siddiqui, MD Johns Hopkins School of Medicine
CME Credits: 0.5

How will this module help me design physical space for improved patient encounters?

  1. Quick and cost-effective techniques to optimize the layout of your clinic's examination rooms and team areas
  2. Answers to common questions about space design
  3. Case studies that show how practices have successfully implemented interior design ideas

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. Implementing solutions for optimal space design can boost team performance, efficiency, engagement and satisfaction, as well as improve patient satisfaction and outcomes.

Optimizing space in medical practices
Release Date: October 2015
End Date: October 2019

Objectives

At the end of this activity, participants will be able to:

  1. Identify quick and cost-effective techniques to optimize the layout of clinic examination rooms and team areas
  2. Utilize technology to encourage patient engagement
  3. Improve the layout of examination and consultation room spaces to ease patient anxiety
  4. Develop team stations to enhance team interactions

Target Audience

This activity is designed to meet the educational needs of practicing physicians.

Statement of Need

As time available for examinations and consultations continues to shrink, the environment where patient encounters occur is pivotal to physician satisfaction and patient satisfaction and engagement. Practices can incorporate proven design solutions to enhance team and patient interactions, which can boost team performance, efficiency, engagement and satisfaction, as well as improve patient satisfaction and outcomes. In this module, physicians will learn how to take simple and cost-effective steps to improve their practice design and consider solutions to improve team satisfaction, workflow efficiency and patients’ safety, health, satisfaction, comprehension and adherence.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA
  • Rita LePard, CME Program Committee, AMA
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Krystal White, MBA, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

Author(s)

  • Nicholas Watkins, PhD, EDRA, Director of Research, BBH Designs
  • Michelle Gandolf-Frietchen, MA, Senior Manager, Market Research & Insights, Cleveland Clinic
  • Zishan Siddiqui, MD, Internal Medicine, Assistant Professor of Medicine, Johns Hopkins School of Medicine

Faculty

  • Jennifer R. DuBose, EDAC, LEED AP Associate Director, SimTigrate Design Lab, Georgia Institute of Technology
  • Deborah Breunig, RN, MBA, EDAC, Vice President Healthcare Marketing, KI
  • Alice Mastrangelo Gittler, MPS, EDAC, Healthcare Interior Design, Design Researcher, BBH Design
  • Kenneth J. Feldman, Ed.D., FACHE, Associate Executive Director, Gouverneur Health
  • Michael Toedt, MD, FAAFP, Family Physician, Cherokee Indian Hospital
  • Gena English, AAHID, RAS, Professional Healthcare Interior Designer
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

References

  1. Collins NL, Miller LC. Self-disclosure and liking: a meta-analytic review. Psychol Bull. 1994;116(3):457-475.
  2. Forgas JP. Affective influences on self-disclosure: mood effects on the intimacy and reciprocity of disclosing personal information. J Pers Soc Psychol. 2011;100(3):449-461.
  3. Greenfield S, Kaplan S, Ware JE, Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102(4):520-528.
  4. Hulka BS, Cassel JC, Kupper LL, Burdette JA. Communication, compliance, and concordance between physicians and patients with prescribed medications. Am J Public Health. 1976;66(9):847-853.
  5. Inui TS, Carter WB. Problems and prospects for health services research on provider-patient communication. Med Care. 1985;23(5):521-538.
  6. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract. 1981;12(3):481-488.
  7. Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340-349.
  8. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
  9. Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department Use. JAMA Intern Med. 2014;174(8):1350-8.
  10. Zadeh RS, Shepley MM, Williams G, Chung, SSE. The impact of windows and daylight on acute-care nurses’ physiological, psychological, and behavioral health. Health Environ Res Design. 2014;7(4):35-61.
  11. Watkins N, Harper E, Zook J, Black A. The search for clinic layouts that care. The landscape of accountable care: how a patient focus is changing the industry at the new Parkland Hospital. Paper presented at: EDRA 45: Environmental Design Research Associations 45th Annual Conference; May 28-31, 2014; New Orleans, LA.
  12. Ajiboye F, Dong F, Moore J, Kallail KJ, Baughman A. Effects of revised consultation room design on patient-physician communication. Health Environ Res Design. 2015;8(2):8-17.
  13. Almquist JR, Kelly C, Bromberg J, Bryant SC, Christianson TH, Montori VM. Consultation room design and the clinical encounter: the space and interaction randomized trial. Health Environ Res Design. 2009;3(1):41-78.
  14. Okken V, van Rompay T, Pruyn A. Room to move: on spatial constraints and self-disclosure during intimate conversations. Environ Behav. 2013;45(6):737-760.
  15. Dazkir SS. Emotional effect of curvilinear vs. rectilinear forms of furniture in interior settings [Masters Thesis]. Oregon State University. 2009.
  16. Arneill AB, Devlin AS. Perceived quality of care: the influence of the waiting environment. J Environ Psychol. 2002;22(4):345-360.
  17. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28(6):657-665.
  18. Pruyn A, Smidts A. Effects of waiting on the satisfaction with the service: beyond objective time measures. Int J Res Marketing. 1998;15(4):321-334.
  19. Ley P. Improving patients’ understanding, recall, satisfaction and compliance. In: Broome AK, ed. Health Psychology: Processes and Applications. Dordrecht, The Netherlands: Springer Science+Business Media; 1989:74-102.
  20. Street Jr RL, Liu L, Farber NJ, et al. Provider interaction with the electronic health record: The effects on patient-centered communication in medical encounters. Patient Educ Counsel. 2014;96(3):315-319.
  21. Kessels RP. Patients' memory for medical information. J R Soc Med. 2003;96(5):219-222.
  22. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421.
  23. Becker F, Douglass S. The ecology of the patient visit: physical attractiveness, waiting times, and perceived quality of care. J Ambul Care Manag. 2008;31(2):128-141.
  24. Ulrich RS. Healing arts: nutrition for the soul. In: Frampton SB, Gilpin L, Charmel PA, eds. Putting Patients First: Designing and Practicing Patient-Centered Care. San Francisco, CA: John Wiley & Sons; 2003:117-146.
  25. Okken V, van Rompay T, Pruyn A. When the world is closing in: effects of perceived room brightness and communicated threat during patient-physician interaction. Health Environ Res Design. 2013;7(1):37-53.
  26. Okken V, van Rompay T, Pruyn A. Exploring space in the consultation room: environmental influences during patient–physician interaction. J Health Comm. 2011;17(4):397-412.
  27. Asan O, Young HN, Chewning B, Montague E. How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care. Patient Educ Couns. 2015;98(3):310-316.
  28. Kumarapeli P, de Lusignan S. Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: multi-channel video study. J Am Med Inform Assoc. 2013;20(e1):e67-e75.
  29. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.

Introduction

The design of a practice influences the relationship between physicians and patients. You can take simple design steps to enhance workflow efficiency and patient safety, as well as patient and team interactions and satisfaction.1-8

Morris Gagliardi, MD

We were inconveniencing our patients and creating unnecessary work for ourselves. Focusing on better wayfinding for patients and grouping like services together in the clinic revealed incredible opportunities for us to better deliver a more efficient, patient-centered experience.

Morris Gagliardi, MD, MBA
Associate Medical Director Gouverneur Health, New York, NY
Space optimization introduction

Five steps for optimizing your physical space

  1. Develop team stations that enhance interactions
  2. Place furnishings to encourage patient engagement
  3. Add positive distractions to alleviate patient anxiety
  4. Reconfigure rooms to feel spacious and welcoming
  5. Connect with patients while incorporating technology
  1. 1

    Well-designed team stations and pods can improve efficiency and strengthen culture

    For example, placing exam rooms close to the team’s work area minimizes the space that must be traveled between tasks and improves visibility to the exam rooms. Creating opportunities for team members to naturally interact improves collegiality and may result in better patient outcomes and lower health care costs.9

  • We don’t have a central work space and can’t afford a major remodel. Do you have any suggestions?

    Some practices have been able to convert a centrally located exam room or office into a team space with minimal remodeling. One clinic created two spaces for MA-provider co-location by converting an MAs' station at one end of the hallway and a providers’ station at the other.

  • What is the ideal layout of a team station?

    An ideal space is quiet and yet still supports communication. For example, glass partitions allow teammates to see each other while conserving privacy and minimizing noise. In addition, many practices have found that co-locating the physician with the other team members increases opportunities to communicate in person, resulting in less messaging, more prompt completion of work and a stronger, more cohesive culture. Access to daylight and outside views will lift providers’ moods and alertness.10

  • What are the benefits of having a team station?

    The care team works more closely with physicians, enabling nurses and medical assistants (MAs) to function more effectively and efficiently and for the team to “gel” as a unit. Team stations that are within visual and physical proximity to examination rooms also help the team develop “situational awareness” (e.g., seeing which rooms are ready to be used, where a call light is on) that helps them manage patient flow throughout the day.11

  • What about noise from dictation or telephone conversations?

    Some practices have created a library-like atmosphere in the co-located space to maintain patient privacy and a quiet work environment. This can be accomplished by doing the following:

    • Team members speak in quiet voices
    • Dictation is done in the exam room with the patient or in sound-absorbing carrels
    • Wall and floor materials are chosen to specifically reduce ambient noise
  1. 2

    Place furnishings to encourage patient engagement

    The arrangement, shapes and types of desks, examination tables and chairs can all work together to encourage productive interactions and eye contact. The patient can sit in a chair to speak with the physician or MA instead of spending the entire visit on the examination table. Computers can be mounted to the wall on a swivel arm or the team can use laptops, so they are free to shift their position and face the patient.

  • What are the best desk shapes for encouraging patient engagement?

    A moderately sized circular or semi-circular desktop allows the physician and patient shared access to the computer screen while still providing the ability to turn to one another for face-to-face discussion.12,13 Moreover, physicians and patients can easily adjust their seating so they can choose to be side-by-side or across from each other. Desktops should be wide enough that a patient sitting across from a physician can choose to keep the physician’s face from dominating the view, easily modify personal space boundaries and share sensitive information without feeling awkward or embarrassed.14

  • Aside from the desk, does the shape of other furnishings matter?

    Rounded, curvilinear chairs, tables and objects are calming and preferred over angular furnishings.15 These also are safer for children and the elderly and in case of falls.

  • Does posture and seating height influence the patient encounter?

    Patients are more likely to comprehend information and be satisfied with their visit when their physicians sit at eye-level, lean forward (showing engagement) and make eye contact. Looking down at the patient, leaning backward into a power position or frequent touching of the patient can make the patient feel uncomfortable.6

  1. 3

    Add positive distractions to alleviate patient anxiety

    Patients will take in your clinic’s surroundings, gathering clues about the quality of care they will receive. This will influence their confidence in the practice and their experience throughout their clinic visit.16

    Being in the physician’s waiting area and examining room is stressful for many people. Waiting can contribute to patient anxiety and dissatisfaction.17,18 Moreover, an anxious patient comprehends and retains less information from the encounter.19-21

    Positive distractions divert attention away from these stressors and create a positive mood.

  • What are some positive distractions that create a feeling of calm and confidence?

    Window views of natural settings and artwork featuring realistic images of natural landscapes have been shown to reduce patients’ stress as well as pain.22 These views and images should be in direct view of the patient while they are waiting and sized so that patients can make out details from where they are seated. Other positive distractions are magazines, informational material or a flat screen set to a patient-education loop. Plants in the waiting room can also ease patient anxiety and create a more natural, comfortable environment.23,24

  • What type of artwork provides the best positive distractions?

    Realistic images of landscapes with high visual depth, healthy flowers and foliage during warm weather, low hills, sweeping views of mountains, calm water surfaces and positive relationships between people are best. Avoid abstract artwork as it can increase anxiety.25

  • Is television an effective positive distraction?

    Televisions can exacerbate the stress of waiting. Patients typically cannot control the programming and program intervals cause patients to be more aware of the actual time that has elapsed.

  1. 4

    Reconfigure rooms to feel spacious and welcoming

    You do not need to tear down walls or build new rooms to make an examination space seem more spacious. Rearranging the location of the examination table, chairs and desk can make a small room feel much more open and comfortable. Brightening up a consultation space with additional lighting, softening harsh overhead lighting or rearranging the furniture can make a smaller consultation space seem more spacious and comfortable to patients.24

Reconfigure rooms to feel spacious and welcoming
  • Place examination tables at an angle to free up wall space for more chairs along the wall
  • Use light, warm-colored paint on the walls and natural, soft artwork
  • Consolidate the amount of “stuff” in the room, such as materials and supplies on countertops or instruments that are left behind after another patient’s procedure
  • Organize the patient education material on the wall, only including what is necessary and up to date
  • Create an effective electronic health record (EHR) solution, such as using a semi-circular desk or laptop. Placing the computer on a desktop or counter that faces a wall will force the physician to face the wall instead of the patient, making the space and experience less positive and engaging

Make the most out of your practice's space. A few simple design steps can improve workflow and care #STEPSforward

  • What are the benefits of having spacious examination rooms?

    In large, open examination spaces, patients tend to feel less anxious, more comfortable, make more eye contact with the physician and are more likely to disclose sensitive information.14,26-27 This response may be related to the actual size of the space, the increased brightness of the space, the ability to see more of the surroundings, increased freedom of movement and perceived freedom. The more comfortable a patient is in the exam room, the more productive the visit will be.

  1. 5

    Connect with patients while incorporating technology

    Increased eye contact during visits and sharing the computer screen with a patient can positively influence patient engagement and adherence.28,29 Mobile or easily shared technology such as laptops, tablets and large monitors can help physicians involve patients in discussing information with them.12

Learn from small changes

One strategy might be to introduce a specific type of computer or desk in an exam room and evaluate how patient encounters in that space compare to others. Some practices conduct time and motion observations to identify bottlenecks and opportunities for improvement.

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Conclusion

The physical space in a clinical practice can impact how the people within that space interact. Thoughtful space-optimization solutions can improve efficiency, engagement and satisfaction for patients and providers alike.

Space optimization conclusion

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References

  1. Collins NL, Miller LC. Self-disclosure and liking: a meta-analytic review. Psychol Bull. 1994;116(3):457-475.
  2. Forgas JP. Affective influences on self-disclosure: mood effects on the intimacy and reciprocity of disclosing personal information. J Pers Soc Psychol. 2011;100(3):449-461.
  3. Greenfield S, Kaplan S, Ware JE, Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102(4):520-528.
  4. Hulka BS, Cassel JC, Kupper LL, Burdette JA. Communication, compliance, and concordance between physicians and patients with prescribed medications. Am J Public Health. 1976;66(9):847-853.
  5. Inui TS, Carter WB. Problems and prospects for health services research on provider-patient communication. Med Care. 1985;23(5):521-538.
  6. Larsen KM, Smith CK. Assessment of nonverbal communication in the patient-physician interview. J Fam Pract. 1981;12(3):481-488.
  7. Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340-349.
  8. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796-804.
  9. Nelson KM, Helfrich C, Sun H, et al. Implementation of the patient-centered medical home: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department Use. JAMA Intern Med. 2014;174(8):1350-8.
  10. Zadeh RS, Shepley MM, Williams G, Chung, SSE. The impact of windows and daylight on acute-care nurses’ physiological, psychological, and behavioral health. Health Environ Res Design. 2014;7(4):35-61.
  11. Watkins N, Harper E, Zook J, Black A. The search for clinic layouts that care. The landscape of accountable care: how a patient focus is changing the industry at the new Parkland Hospital. Paper presented at: EDRA 45: Environmental Design Research Associations 45th Annual Conference; May 28-31, 2014; New Orleans, LA.
  12. Ajiboye F, Dong F, Moore J, Kallail KJ, Baughman A. Effects of revised consultation room design on patient-physician communication. Health Environ Res Design. 2015;8(2):8-17.
  13. Almquist JR, Kelly C, Bromberg J, Bryant SC, Christianson TH, Montori VM. Consultation room design and the clinical encounter: the space and interaction randomized trial. Health Environ Res Design. 2009;3(1):41-78.
  14. Okken V, van Rompay T, Pruyn A. Room to move: on spatial constraints and self-disclosure during intimate conversations. Environ Behav. 2013;45(6):737-760.
  15. Dazkir SS. Emotional effect of curvilinear vs. rectilinear forms of furniture in interior settings [Masters Thesis]. Oregon State University. 2009.
  16. Arneill AB, Devlin AS. Perceived quality of care: the influence of the waiting environment. J Environ Psychol. 2002;22(4):345-360.
  17. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28(6):657-665.
  18. Pruyn A, Smidts A. Effects of waiting on the satisfaction with the service: beyond objective time measures. Int J Res Marketing. 1998;15(4):321-334.
  19. Ley P. Improving patients’ understanding, recall, satisfaction and compliance. In: Broome AK, ed. Health Psychology: Processes and Applications. Dordrecht, The Netherlands: Springer Science+Business Media; 1989:74-102.
  20. Street Jr RL, Liu L, Farber NJ, et al. Provider interaction with the electronic health record: The effects on patient-centered communication in medical encounters. Patient Educ Counsel. 2014;96(3):315-319.
  21. Kessels RP. Patients' memory for medical information. J R Soc Med. 2003;96(5):219-222.
  22. Ulrich RS. View through a window may influence recovery from surgery. Science. 1984;224(4647):420-421.
  23. Becker F, Douglass S. The ecology of the patient visit: physical attractiveness, waiting times, and perceived quality of care. J Ambul Care Manag. 2008;31(2):128-141.
  24. Beukeboom CJ, Langeveld D, Tanja-Dijkstra K. Stress-reducing effects of real and artificial nature in a hospital waiting room. J Altern Complement Med. 2012;18(4):329-33.
  25. Ulrich RS. Healing arts: nutrition for the soul. In: Frampton SB, Gilpin L, Charmel PA, eds. Putting Patients First: Designing and Practicing Patient-Centered Care. San Francisco, CA: John Wiley & Sons; 2003:117–146.
  26. Okken V, van Rompay T, Pruyn A. When the world is closing in: effects of perceived room brightness and communicated threat during patient-physician interaction. Health Environ Res Design. 2013;7(1):37-53.
  27. Okken V, van Rompay T, Pruyn A. Exploring space in the consultation room: environmental influences during patient–physician interaction. J Health Comm. 2011;17(4):397-412.
  28. Asan O, Young HN, Chewning B, Montague E. How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care. Patient Educ Couns. 2015;98(3):310-316.
  29. Kumarapeli P, de Lusignan S. Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: multi-channel video study. J Am Med Inform Assoc. 2013;20(e1):e67-e75.
  30. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.

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