Impact of COVID-19 on medical office buildings
As any seasoned health care planner would tell you, “form follows function.” In other words, the way you intend to deliver health services to your patients should drive the size, configuration, adjacencies and design attributes of the space. Given that the COVID-19 pandemic brought immediate and significant changes to the management of patients seen in physician offices and ambulatory care centers, it is not surprising that myriad building and facility “quick fixes” were implemented to support the radical change in outpatient care delivery. From patients using their cars as waiting rooms, to blue pieces of tape on the floor to ensure social distancing, to makeshift COVID-19 screening centers set up in hospital parking lots, the built environment had to be modified to support the primary goal of keeping patients and staff safe by reducing the transmission risk of COVID-19.
As reported by the Commonwealth Fund in August, early in the pandemic, in-person ambulatory care visits declined by almost 60% due to a combination of patient safety concerns, rapid availability of telemedicine visits as an alternative and local government restrictions. Much of the speculation at that time was around whether outpatient volume would return and, if so, when and how much. By the end of July, in-person weekly ambulatory visit volume leveled off at just 10% below the prepandemic baseline and telemedicine visits plateaued at approximately 7% of the baseline visits. So while telemedicine visits have increased nearly sevenfold since February, patients have in fact returned to see their doctors (Mehrotra, 2020). The questions to ask now are:
• What does the ambulatory patient’s experience look like in this pandemic-aware world?
• How will these changes in patient expectations and experience impact the design of clinics and ambulatory centers?
To safely resume in-person outpatient visits, comply with Centers for Disease Control and Prevention guidelines and local restrictions, and ensure the safety and wellbeing of staff and physicians, the patient-family-staff experience will look different going forward. Previsit communication will include additional information about procedures that minimize the risk of coronavirus transmission to ease patient concerns and screening steps the patient must comply with to be seen. While screening protocols on the day of service will vary by organization, patients will need to arrive in advance of their appointment time to complete necessary screening activities. While the patient is in the facility, efforts will be made to provide for social distancing, hand sanitizer, and availability of masks. The patient’s contact with health care workers and other patients should be limited to the extent possible, as should the patient’s movement within the space. Direct patient rooming to reduce or eliminate time in a shared waiting space should be implemented, and if a room is not available the patient should be provided with a means of notification, such as a buzzer, to enable the patient to wait in an alternative location. Optimally, all providers and staff will come to the patient in the exam room so the patient is not moving between functional spaces within the clinic, such as a vitals alcove, financial counseling office, consult space and checkout desk.
The design of public, patient care and staff support areas will need to be modified to support this new patient-family experience, resulting in a 10% to 20% increase in gross square feet to segregate the circulation of patients and staff as well as accommodate larger exam rooms to account for activity zoning and visitor space. Current planning standards indicate that clinics be programmed at 450 to 650 gross sf per exam room; however, the types of changes that will be discussed will require 550 to 750 gross sf per exam room.
Space efficiencies may be gained by reducing the waiting room size as the expectation is that patients will not wait, but rather will immediately room themselves upon arrival; however, the need to provide a flexible COVID-19 screening area at the entry to the clinic may need to be accounted for.
The circulation pattern of the standard race track clinic design (Figure 1) does not enable the separation of patient and staff traffic flows or social distancing guidelines. Walking by other patients and around staff who are going in and out of exam rooms is a common experience in a clinic with a race track design. Furthermore, staff and support spaces are often located in high-traffic areas of the clinic further increasing the number of individuals a patient is likely to encounter during a visit.
As depicted in Figure 2, a clinic design that provides for an exterior corridor from which a patient accesses the exam room and an inner staff core that allows staff to enter the exam room from an internal door provides for segregation of staff and patient flows, greatly reducing the number of individuals a patient encounters during the visit. In addition, all members of the health care team who need to interact with the patient come to the exam room to see the patient or they may utilize technology, such as a wall-mounted screen. Access to exam room storage from the core space to stock supplies reduces the number of individuals who enter the exam room, further reducing the spread of disease. Exam room zoning for patient care, physician, support and visitor areas and appropriate sizing of the exam room needs to be considered to ensure optimal safety and functionality. An exam room of 120 to 130 net sf will accommodate the functional requirements described.
The clinic design in Figure 2 is often referred to as the Virginia Mason or on-stage/off-stage model and is premised on the Lean principle of patient-centered care. While the gross sf per exam room is greater than that of the race track model, the associated benefits increasing provider efficiency and minimizing burdens put on the patient, together with its ability reduce exposure to other individuals during the visit, make it a model to consider as we adapt our medical office buildings to the new realities of COVID-19 and future pandemics (Weber, 2020).
Featured in the October issue of Health Care & Senior Housing Quarterly