Designing functional and cost-effective outpatient physician practices.

Wondering how best to design space for today's medical practices that accommodates care and budget guidelines? Whether starting from scratch or streamlining current digs, space planning has to meet present medical need; anticipate future growth; enhance, not hobble, patient flow; and hit most, if not all, of the must-have items on the physicians' wish list.

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What seems daunting is in fact quite possible when we develop volume, care delivery and staffing assumptions before the architects even arrive. It's not enough to understand how many patients the practice sees. Rather, it's a qualitative analysis of those numbers--how shall we see patients, where shall we see them and who should see them--that breathes life into quantitative assumptions. To succeed, engage your physicians in this level of discussion, organizing them around these questions and valuing their answers and insights.

Moreover, involving front-line physicians in developing best-practice, care delivery operating processes for a new space secures financial and patient satisfaction benefits, specifically:

* Increased physician/staff productivity

* Improved patient coordination and flow

* Streamlined spatial configuration--neither too much nor too little--to meet today's and tomorrow's needs

When a prominent New England hospital considered relocating its maternal-fetal medicine (MFM) division--placing scattered academic, administrative, clinical and testing services into one new space--leaders needed to explore key questions about care delivery.

Senior consultants set out to secure consensus among administrators and physicians, a challenge too often left to architects to negotiate with, quite frankly, dubious success. By first delineating assumptions about how MFM delivered care, we could then understand the space requirements it would take to get the job done.

Using analysis, prepared with physician participation and buy-in, care delivery was reconfigured to fit into one, streamlined 9,900-square-foot space. With plan in hand, it was time to call the architects.

Here's how to ensure that good, prospective decisions underpin best outcome for practice space, design and build out.

Project growth by service line

A projection of current and expected volume served as the foundation for decision-making about MFM's operational model, provider capacity needs and space requirements. But the common approach--multiplying an hourly productivity rate by the number of physicians to calculate total volume--will backfire when planning for space needs.

Instead, MFM developed this projection by service line and used the information to tailor space to the specific needs of each patient type. For example, the staffing and patient flow process necessary to support patients with gestational diabetes is very different from the resources necessary to support patients pregnant with twins and triplets. As in the development of any volume projection, physician insight is helpful. They understand current referral patterns and the local competition for patients.

It is also important to calculate current volume accurately. Volume figures in the administrator's office rarely match actual patient volume managed on the front line. Correlate volume data with scheduling information to confirm its accuracy in terms of numbers and types of patient visits.

Articulate service delivery processes

Outpatient volume, as well as the types of service clinicians deliver in this setting, burgeoned in the past decade. Operating in space that has not accommodated these changes forced many practices to adopt awkward and inefficient patient intake, flow and coordination processes. For instance, many practices are overstaffed to accommodate exam room configurations that require two nurses or medical assistants when one would do.

With three-plus locations that evolved over time to accommodate newer technologies and additional services, such as genetic counseling, care in the MFM division was fractionalized. Services were channeled into "silos" with little patient integration.

Savvy administrators reasoned, and rightly so, that by occupying one space, the practice could eliminate service redundancy. But what should the model look like? From three greeting desks to one was an obvious fix. More significant changes involved fine-tuning patient flow to design and deliver care that was both clinically innovative and operationally efficient.

Managing the patient visit

MFM leadership understood that space planning was only possible after first examining and reconfiguring the patient visit. Providers developed clinical and operating assumptions for the entire patient care delivery process.

MFM found that a substantial portion of time dedicated to patient care delivery could occur without the patient present. Ideally, administrative and clinical support staff should work behind the scenes to coordinate the patient care required pre- and post-visit, ensuring that all patient/provider interactions are seamless and result in payment.

Specifically, patient intake, registration, scheduling, referral authorization and management, test scheduling and financial management can all be executed on the telephone before the visit.

MFM has a large referral base for gestational diabetes, with a designated nurse practitioner in charge. Consultants worked to coordinate and schedule as much care as possible for these patients in advance. Indeed, all patients benefit from testing, special service needs and even translation assistance arranged prior to the actual visit.

Pre-planning visits leaves less to chance, ensures everyone stays on time and decreases patient wait time. An added bonus is the uptick in patient satisfaction scores that results from anticipating and meeting patient needs without glitches in care coordination and flow.

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Post-visit planning, including referral appointments and testing, as well as scheduling follow-up visits, should be done at the conclusion of that day's visit--ensuring physicians' orders are swiftly executed, increasing the chances of patient compliance and providing the opportunity for pre-visit staff to begin their tasks without time pressure.

On-site patient visit

Having executed a process that anticipates patient needs and completes many administrative functions in advance of the visit, the on-site administrative tasks of confirming registration, collecting co-pays and triggering patient arrival are reduced.

Physicians and other service providers, supported by the pre/post visit management staff, can conduct productive, efficient, quality patient visits. They can do so with the assurance that, to the extent possible, patient needs have been anticipated and scheduled.

In the MFM division, consultants led discussions about on-site patient visits for current and future patients and then designated space accordingly. Because many MFM high-risk patients face serious complications, administrators created a special sub-wait area for mothers who needed emotional privacy.

Space planning also took into consideration medical projections: MFM nurse practitioners will likely assume more case management responsibilities and physicians will increasingly focus on the technological and interpretive side of high-risk obstetrical medicine.

Administrators added generic consult rooms to accommodate these growing trends, factoring in the possibility that some of these services may occur off-site in the future.

Providers and support staff

With a clear understanding of the number of patients to be seen and the kinds of services to provide, and after having reviewed the entire patient care delivery process--pre-, post- and during the visit--the next step is to settle on the number and types of providers and support staff.

Do not assume the practice currently has the correct number of physicians servicing patients. If care delivery has been reconfigured, it is no guarantee the same amount or type of clinical resources is needed.

Because MFM was relocating several services into one shared space, administrators needed to analyze staffing, retool responsibilities and make agreements with providers about:

* The type of provider, for instance, physician, physician's assistant, nurse practitioner, etc., who will deliver specific components of care

* Productivity

* The number/duration of clinical care sessions to be offered

Assumptions were fed into a financial model to determine the number of full-time equivalent physicians and other clinicians required to see the projected patient volume.

It's imperative to conduct this analysis by service line so as not to underestimate the provider capacity needed. Providers may or may not be able to combine visit types or visits and procedures. Obviously, if services are delivered from multiple locations a separate capacity analysis must be conducted for each.

Just as it is necessary to recalculate the provider capacity necessary to deliver care, it is likewise necessary to reconfigure staff support. To ensure optimal operations in MFM's new space, administrators needed to understand:

* Staff assignments, by service line process and function

* A staffing plan, by staffing category

* Delineation of role and tasks, by staffing category

All of this information provided the basis for discussion about how much square footage the division required to support patient flow, what types of equipment were needed and where the equipment would be housed.

Calculating space needs

Armed with physician agreement about volume, service lines, processes, and clinical/administrative staff needs, the discussion about how much space and how it is configured is an intellectual discussion about what physicians need--not an emotional or theoretical discussion about what they want.

Written qualitative and quantitative agreements about operating assumptions provide an opportunity to reopen discussion about space needs in the future. If the assumptions change, so might the space needs. For instance, the addition of new services or an influx of new patients might require expanded space.

However, if those operating assumptions do not change, a problem exists that new or expanded space will not solve. For instance, if a practice needs to hire a number of new part-time physicians, they must spread their sessions over the week, and not bunch them up on one day. That way, new space is not required.

Planning the best healing environments begins with a hard look at how the space is going to be used. Before calling in architects and contractors, physician executives must roll up their sleeves and do the hard work necessary to:

* Forecast current and projected volume by service line

* Articulate the services the practice will deliver, accounting for future trends as much as possible

* Re-examine how care is currently delivered--before, during and after the visit--and then tighten operations by reconfiguring provider and staff responsibilities and tasks.

Consensus is critical among all parties involved. With insight and measurable information, architects can design a comfortable space for providers and patients alike that facilitates optimum care and delivers cost-effective services.

Jayne Oliva is a principal with The Croes*Oliva Group, a medical group management consulting firm, specializing in developing outpatient operational improvement plans for physician practices at major academic medical centers and integrated delivery systems throughout the U.S. She can be reached at [e-mail]. Visit the firm's website at www.croesolivagroup.com.