Woulda, Coulda, Shoulda: Part Two, Post-Occupancy Review

This is the follow up to this post about clinic staff experiencing post-occupancy regrets and how to make resolving their concerns a productive part of the design process.

Perhaps regret is too strong a word here. When I heard that there were a lot of “complaints” about one of our clinics from the staff, I was concerned that the litany of small criticisms that had dogged the construction process (since we were dealing with a contractor who had a very elastic view of quality and schedule), would have to be rehashed in a post mortem.

However, I was delighted to find that our client was more interested in a frank exploration of what worked and did not work for their program in their new facility. They were anxious to hear if there were architectural solutions to the some of the unanticipated challenges they were encountering in their new space. And they were very optimistic that our review of their current clinic use would help to eliminate similar problems in a second clinic which was about to begin construction.

As I mentioned in my previous blog, design of the original clinic space was complicated by several factors:


• The clinic staff was in the process of redefining their care procedures at the same time they were designing their first new clinic facility

• The health care professionals seemed to have a particularly difficult time understanding the architectural drawings during the design process, even with 3-dimensional images

• The health care professionals were not in total agreement about the best way to improve their patient model


One thing that I have learned is that although healthcare is the most people-oriented of processes, the process of providing care defines space needs. Even small changes to the process can have a significant ripple effect on the entire facility. So, let’s talk about their concerns:


The provider areas were too small.

The size of the provider area is established by the number of exam rooms. It is a program ratio that was established by the clinic. Each family practice has a set number of exam rooms, typically 12 or 18. Each provider covers 3 exam rooms. The logic behind this ratio is:


• an MA shows a patient into exam room #1 and takes their history and then goes to exam room #3 to clean up

• the doctor is sees a patient in exam room #2 and then goes to exam room #1 to see that patient

• the MA cleans up exam room #3 and then goes to the waiting room to show in another patient and they take their history. When that is complete the MA goes to exam room #2 to clean up and on and on


It is a rotating system, making the best use of the exam room space and the provider’s time.


Two providers are supported by the following staff:


• 2 medical assistants

• 1 nurse care manager

• 1 care management support


In this building the typical family practice has 12 exam rooms and 4 providers, the total compliment of staff would be:


• 4 providers

• 4 medical assistants

• 2 nurse care managers

• 2 care management support staff


This is exactly what we had provided at Unity, so we explained the original parameters and dug a little deeper. The primary issue seemed to be:


1. The clinic site director was staffing the clinic with 2 exam rooms per doctor instead of 3

If the clinic had truly changed its staffing ratio this was going to cause a huge problem. Because of the way the exam room’s cluster around the provider area to facilitate efficient observation and use by the professional staff, there is no easy or logical way to provide more provider space without sacrificing both exam rooms and provider proximity.

The clinic director indicated that her staffing model was being driven by the provider’s schedule; they were having a difficult time taking care of three exam rooms and going back to their offices after each appointment to write up their notes. Why were the providers going back to their offices to write up notes when we had provided touch down spaces in the corridor?


This raised concern #2:


2. There was not enough touch down space in the corridor and the corridor was too narrow because of staff seated in the corridor


Again, the design team was baffled.

We had provided a touch down space for every three exam rooms. If you understand the rotation described above, you will realize that although the provider has access to a computer in the exam room, he or she will probably need a few minutes of additional time to write up their notes, write prescriptions, etc., before seeing the next patient. To facilitate that function, so they did not have to go back to their office after each patient, we provided a computer in a niche off the corridor for every three exam rooms, so in theory each doctor had a touch down space in the corridor for their own use. They should be standing at the touch down space for a few minutes not sitting in the corridor. Why was this space not available or not adequate? Who was sitting in the corridor?

Well, there wasn’t enough provider space with 2 exam rooms per provider so itinerant providers had taken over the touchdown spaces and were actually sitting in the corridor.  So which came first the chicken or the egg? Was a design problem leading to operational inefficiency or was the clinic a test case which proved that the theoretical model simply did not work?

The Executive Director of the clinic Health Care System was quick to understand the problem. He determined that this was an operational problem and we moved on to the next topic.


3. There is not enough storage space

The building was designed with a large receiving room on the first floor, a 10 X 12 storage closet in each family practice area and storage cabinets in each exam room, so what was the problem?

The receiving room did not have shelves in it and both medical and building supplies were delivered to that space. The mixing of the two types of supplies was a problem for the medical staff, supplies were going missing, large quantities of bulky supplies were filling the receiving room and were not organized for access and use. As a stop gap solution they started to have the medical supplies delivered to an unused wellness space. From there the medical staff would go down and bring up supplies as they needed them. This was a time consuming and inefficient use of professional staff time. The closets in the family practice areas and the cabinets in the exam rooms were not being used at all, because no one had time to stock them.

Again, the design team was surprised. The staff simply did not understand the design intent, so they were not using the spaces properly. Again the Executive Director was quick to understand the problem; they needed a staff person who would manage the supplies; order and receive them in the correct quantities and distribute them daily to the patient rooms. The only design component which was required; locks on the cabinets in the exam rooms to eliminate pilfering.


So, the two major “complaints” turned out to be operational issues which require staffing solutions. In addition, simply by using their new space, the staff had developed a number of refinements that required some design changes. After a series of meetings we were able to implement the following design changes:


• We increased the number of staff at the reception desks (their staffing model had changed)

• We modified the children’s reading area, making it easier to observe from the reception desk and more open to the waiting area

• We modified a large staff conference room to be used as an office/training area for a new Preceptor program which introduces medical student to clinical practice.

• We modified the main waiting area to be used after hours to accommodate large meetings

• We created two separate receiving rooms; one for building supplies and one for medical supplies


I, for one, am looking forward to doing a post occupancy review of the next facility!


December 14th, 2012 | Live & Learn

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