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Outpatient Clinic

by Robert F. Carr NIKA Technologies, Inc. for VA Office of Construction & Facility Management (CFM) Revised by the WBDG Health Care Subcommittee Last updated: 12-30-2010

OVERVIEW

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RELAT ED RESO URCE PAGES

Achieving Sustainable Site Design through Low Impact Development Practices Aesthetic Challenges

Within This Page Overview

Fo r many years the health care system has experienced a co ntinuing decline in the number o f beds required fo r inpatients.

Building Attributes As inpatient care is reduced, there is a co rrespo nding trend Emerging Issues to ward increased o utpatient health care. An o utpatient clinic is Relevant Codes and less expensive to build and o perate than a ho spital. Space need Standards no t be devo ted to "ho tel functio ns" (the typical nursing units o f Major Resources ho spitals), and the extensive dietetic and ho usekeeping areas that acco mpany them. Fire co de requirements are co nsiderably less demanding and mechanical and electrical systems can be simpler. Multiple shifts o f staff are no t required, since the building is usually clo sed at nights and o n weekends, and ho usekeeping can take place after it is clo sed to patients and mo st staff, rather than while it is o ccupied.

Aesthetic Opportunities Air Barrier Systems in Buildings Air Decontamination VIEW ALL RELAT ED (4 3) VIEW RESO URCE PAG E INDEX

By definitio n, all o utpatient facilities are alike in having no o vernight patients. Otherwise, they can range fro m simple physicians' o ffices that pro vide primary care, to large, independent "ho spitals witho ut beds." Outpatient surgical facilities are no w a co mmo n facility type, as the majo rity o f surgical pro cedures may no t require o vernight ho spitalizatio n. An increasing number o f co mmunity-level o utpatient clinics are satellites o f larger medical centers o r systems, and are thus part o f a co mplex that can emphasize co ntinuity o f care.

Almo st all ho spitals already include so me o utpatient diagno stic and treatment spaces. Many o utpatient co nstructio n pro jects are respo nses to ho spitals' increased o utpatient wo rklo ads. Existing o utpatient facilities within ho spitals are expanded, o verhauled, and updated. Such a reno vatio n can serve a number o f impo rtant functio ns in additio n to that o f giving the PDFmyURL.com

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PR O D UC T S & SYST EMS

ho spital a new o utpatient fo cus. It may create impro ved circulatio n patterns o r it may replace o bso lete clinical areas with state-o f-the-art services fo r use by inpatients as well as o utpatients. Light-filled lo bbies can give a friendly new face to ho spitals that had been do ur and intimidating—a new image that is very valuable in to day's co mpetitive climate.

VA Outpatient Clinic, Springfield, MA

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BUILDING AT T RIBUT ES Altho ugh o utpatient facilities may vary greatly in size and in services o ffered, all sho uld have certain co mmo n attributes:

Ef f iciency and Cost - Ef f ect iveness The layo ut o f the clinic sho uld: Pro mo te staff efficiency by minimizing distance o f necessary travel between frequently used spaces Make efficient use o f space by lo cating suppo rt spaces so that they may be shared by adjacent functio nal areas, and by making prudent use o f multi-purpo se spaces Include all needed spaces, but no redundant o nes. This requires careful pre-design pro gramming.

Gro up o r co mbine functio nal areas with similar system requirements

Flexibilit y and Expandabilit y As medical needs, mo des o f treatment, and wo rklo ad will co ntinue to change, o utpatient facilities sho uld: Fo llo w mo dular co ncepts o f space planning and layo ut Use established standard ro o m sizes and plans as much as po ssible, rather than tight and highly specific o nes Be served by mo dular, easily accessed, and easily mo dified mechanical and electrical systems Where size and pro gram allo w, be designed o n a mo dular system basis Be o pen-ended, with well planned directio ns fo r future expansio n

Cleanliness and Sanit at ion Bo th sanitatio n and the appearance o f it are impo rtant go als fo r o utpatient facilities. They are pro mo ted by: Appro priate, durable finishes fo r each functio nal space. Antimicro bial surfaces might be PDFmyURL.com

co nsidered fo r appro priate lo catio ns Pro per detailing o f such features as do o rframes, casewo rk, and finish transitio ns to avo id dirtcatching and hard-to -clean crevices and jo ints Adequate and appro priately lo cated ho usekeeping spaces Inco rpo rating O&M practices that stress indo o r enviro nmental quality (IEQ)

Outpatient Clinic, VAMC Palo Alto, CA

Easy Visibilit y To enco urage its use, the facility sho uld be: Easy to find, clearly visible fro m the appro ach ro ad, with go o d directio nal signage fro m nearby majo r ro ads Easy to reco gnize, with a welco ming image and clear, appro priately lo cated directio nal signage Easy to enter, with visible, well-identified entrance, and a clear ro ute fro m parking

Accessibilit y All areas, bo th inside and o ut, sho uld: Co mply with the minimum requirements o f the Americans with Disabilities Act ( ADA) and, if federally funded o r o wned, with the Unifo rm Federal Accessibility Standards (UFAS) Be easy to use by the many patients with tempo rary o r permanent handicaps

Therapeut ic Environment Altho ugh the needs o f o utpatients are less intense than tho se o f ho spital inpatients, an individual's visit may still be very stressful. Every effo rt sho uld be made to make the o utpatient visit as unthreatening and co mfo rtable as po ssible, and to make the patient's experience mo re like go ing to a do cto r's o ffice than to a ho spital. This can be acco mplished by: Using familiar and no n-institutio nal materials with cheerful and varied co lo rs and textures Opening up an inwardly directed enviro nment with views o f landscaped co urtyards and o ther o utdo o r spaces, particularly fro m waiting spaces. Nature scenes may be pro vided if o utdo o r view is unavailable.

Using cheerful and varied co lo rs and textures, keeping in mind that so me co lo rs are inappro priate and can interfere with pro vider assessments o f patient's pallo r and skin to nes, diso rient o lder o r impaired patients, o r agitate patients, staff, and particularly so me psychiatric patients. See also VA Interio r Design Manual Admitting ample natural light wherever feasible and using co lo r-co rrected lighting in interio r spaces, which clo sely appro ximates natural daylight Pro mo ting patient dignity and privacy by visual screening within exam ro o ms and so und insulatio n between exam and co nsultatio n ro o ms and o ther spaces Enco uraging patient independence by a patient-o rientated layo ut, with clear and PDFmyURL.com

unco mplicated patient ro utes, visual cues, and clear signage Pro viding quiet areas fo r meditatio n/spiritual renewal, such as, in larger facilities, quiet ro o ms, and meditatio n gardens Ensuring grades are flat eno ugh to allo w easy mo vement, and sidewalks and co rrido rs are wide eno ugh fo r two wheelchairs to pass easily Ensuring entrance areas are designed to acco mmo date patients with slo wer adaptatio n rates to dark and light; marking glass walls and do o rs to make their presence o bvio us

Aest het ics Aesthetics is clo sely related to creating a therapeutic enviro nment (ho melike, attractive). Also , aesthetics is impo rtant to the clinic's public image and is thus an impo rtant marketing to o l, bo th fo r patients and staff. Aesthetic co nsideratio ns include: Increased use o f natural light, natural materials, and textures Use o f artwo rk Attentio n to detail, pro po rtio ns, co lo r, and scale Bright, o pen, genero usly scaled in public spaces Ho melike and intimate scale in patient ro o ms and o ffices Signage that pro mo tes o ptimal way-finding, satisfies the o rientatio n needs o f the first-time patient, allo ws easy navigatio n, and pro vides highly visible reference po ints immediately adjacent to each majo r entrance Use mechanical do o r o peners to assist in entering and leaving the facility

Securit y and Saf et y In additio n to general safety co ncerns o f all buildings, clinics have several particular security co ncerns: Pro tectio n o f clinic pro perty and assets, including drugs Pro tectio n o f patients, including incapacitated patients and staff Vio lent o r unstable patients need to be co ntro lled safely Large, pro minent, publicly-o wned clinics may be po tential terro rism targets

Sust ainabilit y Clinics are public buildings that have an impact o n the enviro nment and eco no my o f the surro unding co mmunity. They are majo r users o f energy and water and pro duce large amo unts o f waste. Because clinics place demands o n co mmunity reso urces they are natural candidates fo r sustainable design.

Sectio n 1.2 o f VA's HVAC Design Manual is a go o d example o f health care facility energy co nservatio n standards that meet EPAct 20 0 5 (PDF 1.3 MB, 550 p g s ) and Executive Order 13423 requirements. The Energy Independence and Security Act o f 20 0 7 (EISA) (PDF 740 KB, 310 p g s ) pro vides additio nal requirements fo r energy co nservatio n. Also see LEED's (Leadership in Energy and Enviro nmental Design) USGBC LEED fo r Healthcare .

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Relat ed Issues The HIPAA (Health Insurance Po rtability and Accessibility Act o f 19 9 6 ) regulatio ns address security and privacy o f "pro tected health info rmatio n" (PHI). These regulatio ns put emphasis o n aco ustic and visual privacy, and may affect lo catio n and layo ut o f wo rkstatio ns that handle medical reco rds and o ther patient info rmatio n, paper and electro nic, as well as patient acco mmo datio ns."

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EMERGING ISSUES A co ntinuing pro liferatio n o f specialized, o ne-service facilities: dialysis centers, cancer centers, surgery centers, heart centers, etc.

A gro wing interest in mo re ho listic, patient-centered treatment, which might include, amo ng o ther things, the pro visio n o f a mini-medical/health care library and co mputer terminals, so patients can research their o wn co nditio ns and treatments.

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RELEVANT CODES AND STANDARDS Co de requirements fo r medical o ffice buildings are much less restrictive than tho se fo r ho spitals.

Lo cal building co des will largely go vern. Ho wever, federal facilities o n federal pro perty generally need no t fo llo w lo cal and state co des, but fo llo w federal regulatio ns.

Outpatient facilities o perated under a ho spital's license o r requiring separate state licensing and accreditatio n will be go verned by additio nal regulatio n. Many states base licensing o n the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed belo w as a reso urce, and thus that vo lume acquires regulato ry status.

State and lo cal building co des are based o n the mo del Internatio nal Building Co de (IBC). Federal agencies are usually in co mpliance with the IBC except NFPA 10 1 (Life Safety Co de), NFPA 70 (Natio nal Electric Co de), and Architectural Barriers Act Accessibility Guidelines (ABAAG) o r Unifo rm Federal Accessibility Standards (UFAS) takes precedence."

Since clinics treat patients who are reimbursed under Medicare, they must also meet federal standards, and to be accredited, they must meet standards o f the Jo int Co mmissio n o n the Accreditatio n o f Healthcare Organizatio ns (JCAHO). Generally, the federal go vernment and JCAHO refer to the Natio nal Fire Pro tectio n Asso ciatio n (NFPA) mo del fire co des, including Standards fo r Health Care Facilities (NFPA 9 9 ) and the Life Safety Co de (NFPA 10 1).

The American with Disabilities Act ( ADA) applies to all public facilities and greatly the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG) o r the Unifo rm Federal Accessibility Standards (UFAS) apply to federal and federally funded facilities. The technical requirements do no t differ greatly fro m the ADA requirements. See WBDG Accessible.

Federal agencies that build and o perate o utpatient clinics have develo ped detailed standards fo r PDFmyURL.com

the pro gramming, design, and co nstructio n o f their facilities. Many o f these standards are applicable to the design o f no n-go vernmental facilities as well. Amo ng them are: Department o f Veterans Affairs(VA), Office o f Co nstructio n & Facilities Management Technical Info rmatio n Library co ntains many guides and standards, including: Design Guides fo r planning ho spital based ambulato ry care clinics, co mmunity based o utpatient clinics, satellite o utpatient clinics, and ambulato ry surgery clinics. This info rmatio n library also includes Design Manuals o f technical requirements, equipment lists, master specificatio ns, ro o m finishes, space planning criteria, and standard details.

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MAJOR RESOURCES WBDG Federal Mandate Executive Order 13423 Technical Guidance Products and Systems Building Envelo pe Design Guide

Websit es See WBDG Health Care Facilities fo r generic health care facilities websites

Publicat ions Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibro ck and Debra Harris. New Yo rk: Jo hn Wiley & So ns, Inc., 20 11.—Inno vative design so lutio ns in key areas such as lighting, aco ustics, co lo r, and finishes Design Planning for Freestanding Ambulatory Care Facilities by Bill Ro stenberg. Chicago : AHP, 19 8 6 .

Emergency Department Design: A Practical Guide to Planning for the Future by Jo hn Huddy and Michael T. Rapp. Irving, TX: ACEP (American Co llege o f Emergency Physicians) 20 0 0 .

Healthcare Facility Plannning: Thinking Strategically by Cynthia Hayward, AIA, FAAHC, ACHA. Health Admnistratio n Press and the American Co llege o f Healthcare Executives, 20 0 5.

Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition , by Jain Malkin. New Yo rk: Jo hn Wiley & So ns, Inc., 20 0 2.

Primary Health Care Centers by Martin Valins. Essex: Lo ngman Gro up UK Ltd, 19 9 3.

See WBDG Health Care Facilities fo r generic health care facilities publicatio ns

Tools SpaceMedGuide-A Space Planning Guide fo r Healthcare Facilities —a po pular planning to o l pro viding state-o f-the-art planning metho do lo gies, industry benchmarks, and planning tips.

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