2EBIRTH OF A CLINIC A design workbook for architecture in general practice and primary care
#ONTENTS Acknowledgments
4
Foreword
5
Introduction
6
Why bother?
7
The fears
9
D.E.S.I.G.N. – A way of thinking about the architectural needs of general practice
22
Hovering above our community Zoning/land use 25
Transport
43
26
Service access
43
Safe
27
Our community – demography
44
27
Our community – cultures and subcultures
45
Our community – a needs analysis
46
Safe for staff Safe for patients
27
10
Checklist of principles for safety
28
For staff
10
What is design?
10
11
43 43
Efficient
10
For the bottom line
41
Diverse
For patients
The benefits
Our community
Innovative
29
Green
30
Neighbourly
31
The scope of architectural design
13
The big picture – health trends
The design process
13
Trends in morbidity
33
Our practice
50
The feel, character, culture and style of our practice
52
The function and operation of our practice
53
Our practice – its life stage and maturation
54
The whole is greater than the sum of the parts
56
35
Adjacency
56
13
Health promotion and disease prevention
35
Orientation
56
Do the groundwork first
13
Chronic disease
35
Overall functional issues
56
Create inclusive, accountable leadership
13
Mental health and wellbeing
36
Be a bower-bird
14
Indigenous health
36
See design as a ‘wicked problem’
14
Changes in health technology
37
14
Increased demands on the workforce
37
Think ‘long term’
Multiple ‘bottom lines’
Metaphors
19
Meetings between experts
19
Metaphor – practice as developing person
20
Metaphor – practice as participant in a network
20
Metaphor – practice as an embodiment of culture
20
Increasing attention to occupational violence and safety 37 Changes in the models of health care
38
Patient centred care
38
Lean thinking
38
Greater teamwork
39
57
Appraisal of the options – stay or move
58
Looking at our current place – impressions
58
Looking at location – growth
58
Location – amenity
58 Rebirth of a clinic
Design as a dialogue among experts 17
Bigger is not necessarily better
2
#ONTENTS
Working with an architect – managing a project Working with an architect
59
The specifics – spaces that have identified purpose
68
61
Entrance
70
Finding your architect
61
Reception area
71
Finding the right architect
61
Patient waiting area
74
Consulting rooms
76
The stages of the project
61
Feasibility and briefing
61
Other consultants
61
Schematic design
62
Design development
Treatment room
79
Observation area/ward
82
62
Sterilisation area
83
Design approvals
62
Computer/server room
84
Contract administration
62
Stock/storage room
85
Cost control
62
Managing time
63
Mothers/fathers room
86
The architects’ fee
63
Toilets/shower
87
Kitchen/staff room
88
Meeting rooms
89 90
Evaluation
64
Evaluation
66
Library/education area
‘Context’, ‘mechanism’ and ‘outcome’
66
Car park/alternate transport (bike/scooter) parking
91
Garden and paths
92
The Living Lab
67
94
References
95
ISBN 978-0-86906-289-0 This workbook was authored by Ian Watts (RACGP), Graham Crist (RMIT University), Judy Evans (RACGP) and Brendan Jones (Antarctica Group Pty Ltd Architects and Designers) Graphic design by Patricia Tsiatsias Disclaimer This publication has been devised to assist general practitioners who may be considering renovations or rebuilding the physical environment where primary care is dispensed to their patients. It is hoped that in providing some ideas put to us by experts and others who have been through the process that this publication may be useful in drawing attention to the multifarious considerations that should receive the attention of your own professionals. It is hoped that this publication may assist you and professionals engaged by you in the formulation of concepts when designing the physical environment in which you practice. On no account should this book be relied upon, nor is it intended as, a substitute for advice of professionals trained in the relevant fields. No liability will arise as a consequence of reliance on this publication. This material is printed using vegetable based inks onto 100% recycled stock.
Rebirth of a clinic
Resources
© The Royal Australian College of General Practitioners
3
)NTRODUCTION
When we set out on the task of designing this guide, we wanted to achieve three things. We wanted to develop something practical. We wanted to create something which reflected the current challenges for general practices – their increasing size and multidisciplinary nature, their focus on excellence in education, the importance of safety for both patients and the people who work in the clinics, and the ongoing pressure to manage costs. We also wanted to engage as many people as possible, and thus harvest the wisdom of members of both the architectural and health professions. We hope we have achieved all three of these. Our work had a number of steps.
In late 2007, the RACGP provided a design brief for a second and third year design studio at RMIT and hosted a ‘design competition’ for those students. Effectively, this is a semester-long subject in which the students focus on a particular design challenge. Many of the images of designs shown here were produced in the RMIT Architecture Program studio ‘Rebirth of the Clinic’ with the architecture students, supervised by Graham Crist and Brendan Jones in 2007. The designs are at conceptual stage and are intended to demonstrate a particular approach to questions of primary care. We have used them to illustrate questions and ideas. In some places we have used them, consciously, to challenge preconceptions and existing thinking about general practices and primary care more generally.
Finally, we took the diverse ideas into general practices. We listened to the problems and aspirations of working doctors and their teams. We heard their stories of success and failure, and incorporated as much as possible into the final workbook. We’ve designed the workbook so that you can write on it, draw on it, paste into it – then use it as briefing document. We hope you enjoy using it.
Dr Huy Quoc An
Mr Graham Crist
Rebirth of a clinic
The project began with discussions among working GPs at the RACGP National Standing Committee – GP Advocacy and Support, about the ongoing demand for a contemporary and practical guide. These took on a greater urgency following the murder of Dr Khulod Maarouf-Hassan in 2006.
Forging the partnership between the RACGP and RMIT University’s School of Architecture and Design was our next step.
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7HY BOTHER
The benefits
For staff
Just as medicine has increasingly moved toward ‘evidence based medicine’, health care design is increasingly guided by rigorous research linking the physical environment of hospitals to patient and staff outcomes, and is moving toward ‘evidence based design’.2
Practices that retain staff are likely to be those that have safe, well-designed working environments, and staff retention ultimately leads to better health outcomes for patients.
Studies reveal the profound impact of the physical environment on a wide range of areas, from patient outcomes and length of hospital stay to medical errors and staff stress.3 For patients Rigorous studies link design features (such as natural lighting, views of nature, and artwork) to improved patient safety, reduced stress, improved outcomes for patients, faster recovery, less pain medication, decreased sleep disturbance, and improved overall health care quality.2,4
Rigorous studies link a well-designed physical environment to: sÂŹ AÂŹREDUCTIONÂŹINÂŹSTAFFÂŹSTRESSÂŹANDÂŹFATIGUE sÂŹ ANÂŹINCREASEÂŹINÂŹEFFECTIVENESSÂŹINÂŹDELIVERINGÂŹCARE 2 For the bottom line Best practice design can employ ‘passive’ features (eg. using particular materials to improve insulation or acoustics, consistent shelving layouts to reduce risks or error) that improve workforce productivity and reduce impact on the environment without the cost of additional staff and resources. Although there appear to be no published studies on the economic benefit of good design in general practice and primary care, a study on hospital design reported that the estimated savings (from reducing harm, for example) and revenue gains (from improved patient flow, for example) nearly recaptured the incremental investment in better building in one year.5
Well considered design can certainly produce efficiencies and enhance safety. Beyond that it can enhance the patient experience. If that experience is central to primary care, then it is worth bothering with.
Rebirth of a clinic
“Researchers have shown that health care buildings, equipment, furnishing, displays, signs, colors, art, landscape, and other sensory stimuli have a disproportionate impact on customers’ overall evaluation of the service provided by those facilities. However, most health care facilities have yet to incorporate the fruits of this research.�5
Magin and colleagues found that as many as 64 percent of GPs are exposed to work related violence in any 12 month period.6
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$ % 3 ) ' .
! WAY OF THINKING ABOUT THE ARCHITECTURAL NEEDS OF GENERAL PRACTICE General practitioners and other health professionals in primary care often seek, consciously and unconsciously, to satisfy a number of demands within the designs for their practices. The mnemonic D.E.S.I.G.N. was developed to capture the characteristics that many GPs want to consider in designing or renovating a practice. Australian general practices are diverse. They want to be efficient. They seek to be safe for both patients and health professionals. General practice seeks to innovate. General practitioners are often keen to be ‘green’. General practice is a key part of a community, and a part of the neighbourhood in both a physical and abstract way.
Rebirth of a clinic
The mnemonic is not prescriptive, but rather a starting point for considering ideas that can be incorporated into the design process.
Image courtesy Fai’zan Shah
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4HE SPECIFICS ¯ SPACES THAT HAVE IDENTIFIED PURPOSE
‘L’ or ‘U’ shaped desks allow the receptionist to turn away when giving personal information over the phone. More desk area is made available for easy reach. Typing desk height is lower than a general desk. Avoid having patient files in public view or a desk top at counter level. Air flow should not be directed toward the receptionist.
A suitable sized notice board should be placed in view of the entrance reception area. Chairs should be located 3 metres away from the reception desk.
Rebirth of a clinic
A suggested ideal section through the reception area showing hidden filing, correct reception desk design, and air pressurised to flow away from the receptionist.
Reproduced from The design of doctors’ surgeries, 1984
Combining a desk and counter provides a 360 mm higher counter to give privacy to the desk and a writing surface for the patient.
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4HE SPECIFICS ¯ SPACES THAT HAVE IDENTIFIED PURPOSE
s¬ 4HESE¬CONSULTING¬ROOM¬DESIGNS¬ILLUSTRATE¬THE¬ FEASIBILITY¬OF¬DESIGNING¬TWO¬EXIT¬POINTS¬IN¬ CONSULTING¬ROOMS ¬WITH¬THE¬CLINICIAN¬SEATED¬ CLOSE¬TO¬THE¬EXIT¬POINT¬
s¬ 5NNECESSARY¬BENDING¬TO¬THE¬mOOR¬ CAN¬BE¬ELIMINATED¬BY¬INSTALLING¬ POWER¬POINTS¬AT¬DESK¬AND¬ EQUIPMENT¬HEIGHT
s¬ %XTRA¬SEATING¬SPACE¬MEANS¬THAT¬PATIENTS¬CAN¬ INVITE¬EXTENDED¬FAMILY¬AND¬FRIENDS¬TO¬ACCOMPANY¬ THEM¬DURING¬THE¬CONSULTATION ¬4HIS¬MAY¬PROVIDE¬ GREAT¬COMFORT¬TO¬MANY¬PATIENTS¬WHO¬FEEL¬ANXIOUS¬ ABOUT¬A¬MEDICAL¬CONCERN
s¬ !DDITIONAL¬CONSIDERATIONS¬ NOT¬SHOWN ¬INCLUDE ¬ n¬ FOOT¬OPERATED ¬@HANDS FREE ¬TAPS¬ ¬ n¬ ADJUSTABLE¬EXAMINATION¬COUCHES ¬ n¬ ¬GOOD¬LIGHT¬FOR¬EXAMINATION¬BY¬ NATURAL¬AND¬CANDESCENT¬LIGHT
s¬ /NE¬SET¬OF¬DRAWINGS¬SHOWS¬HOW¬TO¬DESIGN¬ CONSULTING¬ROOMS¬WITH¬EXAMINATION¬BEDS¬ POSITIONED¬AWAY¬FROM¬THE¬WALL ¬PROVIDING¬ ¬DEGREE¬ACCESS¬WHEN¬EXAMINING¬PATIENTS s¬ 4HE¬LOWER¬DRAWING¬SHOWS¬THAT¬HOWEVER¬ DESIRABLE ¬IT¬IS¬SOMETIMES¬NOT¬PRACTICAL¬TO¬ INCORPORATE¬A¬STANDALONE¬EXAMINATION¬COUCH¬ IN¬THE¬CONSULTING¬ROOM s¬ "OTH¬DESIGNS¬ILLUSTRATE¬AN¬UNCLUTTERED¬CONSULTING¬ ENVIRONMENT¬ 3EE¬@4HOUGHT¬BOX
Thought box
s¬ %XAMINATION¬EQUIPMENT¬IS¬MOUNTED¬ON¬THE¬WALL¬FOR¬EASY¬ACCESS¬AND¬TO¬KEEP¬mOOR¬SPACE¬ UNCLUTTERED ¬4HE¬SAME¬EQUIPMENT¬IS¬AVAILABLE¬IN¬EACH¬CONSULTING¬ROOM
Rebirth of a clinic
s¬ #ONSULTING¬ROOMS¬ARE¬NOT¬STOREROOMS ¬A¬TROLLEY¬WITH¬MULTIPLE¬DRAWERS¬ON¬WHEELS¬ PROVIDES¬NECESSARY¬EQUIPMENT¬SUCH¬AS¬SWABS ¬SPECIMEN¬JARS ¬NEEDLES ¬AND¬SYRINGES ¬ 4HE¬TROLLEY¬CONlGURATION¬IS¬THE¬SAME¬FOR¬EVERY¬CONSULTING¬ROOM ¬A¬CLINICIAN¬WILL¬HAVE¬ ACCESS¬TO¬THE¬SAME¬EQUIPMENT¬NO¬MATTER¬WHICH¬ROOM¬THEY¬ARE¬WORKING¬FROM ¬4HESE¬ TROLLEYS¬ARE¬RESTOCKED¬BY¬PRACTICE¬STAFF¬AT¬THE¬END¬OF¬THE¬DAY
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