Facility Design: Cultivating Collaboration in the Back Office

Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care and is Practice Management Editor of The Journal of Urgent Care Medicine.

Urgent message: To move patients through the center quickly, urgent care demands near-constant communication among providers and staff. Eliminating enclosed provider offices in favor of shared workspaces promotes back office collaboration while keeping providers focused on clinic activities in real time.

Urgent care reflects the seismic shift occurring in healthcare—traditional, provider-centric approaches of doctors’ offices and hospitals giving way to an innovative, patient-driven focus on convenience, affordability, and customer service delivered in a collaborative, team-oriented environment. As a result, urgent care operators have taken their cues in site selection and facility design from retail and hospitality leaders. But the neatly finished, high-traffic, high-visibility location that’s necessary to draw patients off the street and produce quality outcomes typically comes with high rents. To compensate, operators must continually find ways for their centers to “do more with less.”

As you approach the development of your urgent care center, there remains one potentially thorny issue to consider: with space now at a premium, do you part with the formerly standard, private physician’s office in favor of an “open” floor plan with no personal workspaces? Or are you of the opinion that physicians (and particularly the center’s medical director) have earned the privilege and status afforded by, among other things, a private office?

Arguments for an Enclosed Provider’s Office
As one of the current trends in healthcare design calls for cutting costs via substantially decreasing facility footprints, the areas previously allotted for private offices are increasingly being repurposed into extra floor space for open-plan layouts with physicians working in communal “stations” alongside other providers, nurses, technicians and assistants. However, there are several valid reasons why an urgent care operator might be swayed to buck this trend and include a private physician’s office in the center’s floor plan:

• HIPAA compliance. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created to protect individuals’ private health information, with hefty fines imposed on healthcare providers for noncompliance. A personal office allows a physician to dictate charts or converse with patients—either over the phone, by video consult, or in person—without fear of other patients inadvertently overhearing the consultation. Likewise, patient charts and electronic devices used to access electronic health records are more easily safeguarded in an office with a closed, lockable
• Apart from HIPAA, there are plenty of common occurrences in which urgent care providers need to have a confidential discussion with an employee or complete some heads-down work without distractions. Oftentimes, providers simply desire a few minutes alone to get organized and recharge between patients.
• Having a private office helps reinforce the provider’s importance to the center’s leadership team, particularly when others, such as the business manager, have their own offices. An office distinguishes the provider from the rest of the clinical staff who doesn’t have offices. It also sends a positive message that the center’s ownership places a high value on the provider’s position within the organization.
• A private office can help a physician leader “settle in” and solidify their attachment to the urgent care center. Most doctors faced with the prospect of working in an open-plan office express worry that they will have no place for important keepsakes such as family photos, diplomas, and books. Having a private workspace to personalize and decorate can help the provider establish a strong sense of engagement and ownership at the center, and provide an incentive to work toward building a successful and thriving practice.
• Awkward culture change. Removing an employee’s private office while implementing an open-plan layout can be perceived as a “take away.” This in part explains why organizations encounter so much difficulty getting their staff to buy in to communal workspaces, and why physicians who count themselves among the center’s most important team members are especially resistant to the idea. When a practice is acquired by a group who wants to convert the facility to an open-plan office, there must be a considerable effort undertaken to get providers to understand and accept the culture change, while keeping them on-board with the center’s long-term
• Recruiting and retention. The United States is bracing for an acute shortage of primary care physicians in the next decade. When demand exceeds supply, it stands to reason that the resultant smaller pool of physicians will have more choices of where to practice. Even if having an office is not a “deal killer,” when faced with otherwise equal career options, it can serve as a “perk” for recruiting and retention. Given the exorbitant costs of replacing a physician—not only in terms of direct recruiting and onboarding expenses, but also bringing in interim providers and the potential loss of the departed doctor’s regular patients—absorbing the rental cost of a private office may be a money-saver if the lack/removal of a private office leaves the physician dissatisfied and/or with a wandering

Opening Up the Back Office
Healthcare architects and designers have anticipated the enormous strain an aging and increasingly ill population will have on medical facilities nationwide, and they are rightly espousing reducing costs, more efficient use of space resources, and flexibility, innovation, and collaboration in care models. To this end, here is a breakdown of the reasons why an urgent care operator may decide to forgo allotting space for a physician’s office:

• Private offices disrupt clinic flow. In the economics of urgent care, speed is key. Door-to-door time directly correlates to patient satisfaction, which drives future revenue through repeat visits, positive online reviews, and word of mouth. Additionally, labor is the largest operating expense—meaning the more efficient providers and staff can be (ie, maximizing the number of patients each employee sees per hour), the more profitable a center will be. The absence of a private office eliminates the potentially distracting temptations of idle web-surfing, email checking, and television watching behind closed doors, and helps the physician stay focused on maintaining patient throughput.

• Clinics often have more providers than they do space. Many providers enjoy working in urgent care due to the “work-life balance” of 12-hour shifts followed by multiple days away from work. To cover all shifts, centers frequently use floating, flexible or per diem labor, and considering how many different physicians may rotate through a given urgent care center, it may seem impractical to assign a private office to any one individual when they’ll actually occupy it only part of the time.

• High retail rent means all space must be used judiciously. The high traffic counts and strong traffic visibility of a retail location are needed to raise awareness of an urgent care center. However, due to retail’s high rental rates per square foot, all available space must be optimized toward making the center’s operations as efficient and streamlined as possible. This means that the additional square footage required for a separate private physician’s office might instead have to be used for “revenue-producing” patient

• Open workspaces can curb potential sexual harassment claims. When it comes to dealing with sexual harassment claims in a medical practice, most experts agree that prevention is the best approach. The same goes for workplace bullying and toxic gossip. If there are no private offices, then there are fewer closed-off, private places in which an incident can occur either between either a physician and a patient or a physician and a co-worker. Keeping all interactions in the view of others helps prevent “he-said; she-said”

• Privacy needs can be accommodated. Just because a physician doesn’t have a private office at the urgent care center doesn’t necessarily mean that they will never have a private moment. Newer centers without private offices are instead being designed with quiet rooms, consultation rooms, conference rooms, phone rooms, or provider lounges to accommodate physicians’ need for occasional privacy while practicing in an open-plan office layout. In centers in which a provider is assigned a block of exam rooms, one room can be used to store personal belongings, for documentation, and staff instruction while the others are used for

• Changing provider expectations. The lack of a private office is generally not a deal-breaker for today’s physicians, especially younger physicians who are willingly embracing collaboration and technology. Most likely, a provider’s friends who work in other fields—including law, engineering, and business—work in open-space arrangements. In many corporate cultures there is no concept of personal space—everything belongs to the company. Also, the prevalence of handheld computing devices, with their abundance of powerful medical apps, tends to engender and support a more mobile medical workforce. Doctors now laud the ability to quickly store and retrieve medical information, take notes and dictation, log in to their PC remotely, and monitor patient vital signs all from a handheld device. For providers who have never owned their own practice, they likely have not expected an office and may actually prefer the flexibility of working wherever,

Conclusion
The decision whether to include a private physician’s office in an urgent care center ultimately has to align with the core values and the culture of the organization—not to mention the bottom line. Is a physician’s office an indispensable tool for running a medical practice smoothly, or is it a waste of money and precious real estate? Are collaborative, streamlined care models and lean principles just the latest trend, or do they reside at the forefront of the most transformative era that the healthcare industry has ever undergone? Whatever design a center adopts, the end result should always be the same: quality medical care and an outstanding patient experience.

Alan A. Ayers, MBA, MAcc

President of Experity Consulting and is Practice Management Editor of The Journal of Urgent Care Medicine