1 Ambulatory Care Design, Professional Offices, and Bedless Hospitals

Chapter 10: Ambulatory Care Design, Professional Offices, and Bedless Hospitals

The Evolving Healthcare Landscape: From Traditional to Ambulatory

• Traditional Medical World:

  • Historically, a clear division existed between hospitals and doctors' offices.

  • Doctors' offices were primarily for examination, evaluation, and simple routine procedures (e.g., inoculation, blood draws).

  • Surgery was almost exclusively reserved for hospitals, often requiring inpatient admittance even for minor procedures.

  • This system seemed "natural, inevitable, and right" for those who grew up under it.

• The Paradigm Shift:

  • Driven by factors like cost containment and managed care, the traditional system has become less viable.

  • Barriers between private practice and hospitals are dissolving due to ongoing changes.

Hospital Perspective: Adapting to Outpatient Dominance

• Challenges and Restructuring:

  • The past three decades saw periods of hospital construction booms, but the sustained trend has been toward increasing bed vacancies.

  • Many administrators initially viewed this trend with alarm.

  • Others successfully rethought the hospital's role beyond overnight stays, restructuring for increased ambulatory (outpatient) care.

• Shifting Revenue Mix (American Hospital Association Data):

  • Early 1980s: Fewer than $12\%$ of total U.S. hospital revenues were outpatient-related.

  • Mid-1980s: This figure increased to $23\%$, reflecting a $92\%$ growth in the outpatient market segment.

  • Early 1990s: A significant number of hospitals reported $40$ to $60\%$ of revenues from outpatient services.

  • Mid-1990s: The revenue mix for most hospitals was approximately $50\%$ outpatient and $50\%$ inpatient.

  • Twenty-first Century: The ratio nearly reversed to $30\%$ inpatient and $70\%$ outpatient.

  • While the hospital bed vacancy rate slowed in the early 2000s, the shift in outpatient versus inpatient revenue ratios may be permanent.

Physician Perspective: Decline of Solo Practice and Rise of Group Practices

• End of the Solo Practitioner Era:

  • The "iconic norm" of the solo practitioner in American medicine is virtually over.

  • Contributing Factors to Decline:

    • Increasing competition among physicians.

    • Cost-containment pressures leading to more restrictive reimbursement practices.

    • High cost of maintaining malpractice liability protection.

• Explosion of Group Practices:

  • Group practices (typically three or more physicians) share patient care and business operations.

  • They possess combined financial clout to purchase equipment and office facilities for services previously exclusive to hospital-based ambulatory care.

Emergence and Evolution of Freestanding Facilities

• Early Freestanding Facilities:

  • Starting in the 1980s, entrepreneurial physicians and others began establishing freestanding facilities to offer urgent, episodic, and primary medical care, challenging hospitals and solo practitioners.

  • Growth Statistics:

    • 1980: Fewer than $300$ such facilities nationwide.

    • Seven Years Later: Increased by $400\%$ to over $3,000$ facilities.

    • Early 1990s: Approximately $5,500$ freestanding facilities were operating, handling about $63$ million patient visits annually, compared to $5$ million in 1980.

    • Beginning of 21st Century (AHA data): $22\%$ of facilities were freestanding outpatient centers.

  • Financial Viability Challenges: Despite phenomenal growth, these facilities rarely achieved financial viability. In the 1990s, only about $30\%$ were profitable.

• Freestanding Ambulatory Surgery Facilities:

  • Continue to develop concurrently despite profitability struggles of other freestanding facilities.

• Other Freestanding Facilities (post-1980s growth):

  • Diagnostic (or imaging) centers.

  • Specialized treatment centers focusing on specific areas (e.g., eye, heart, elderly, cancer patients, women).

Hospitals' Responses and New Business Models

• Affiliation and Acquisition: Hospitals are showing increased interest in affiliating with or acquiring group practices.

• Expanding Outpatient Programs: Hospitals are expanding outpatient services to offer the same "convenience" care found in freestanding facilities.

• Evolution of Emergency Departments (EDs):

  • Initially, freestanding urgent care centers were perceived as direct competition for hospital EDs.

  • Hospital EDs expanded, adding space for less acute urgent care and upgrading to improve efficiency and patient experience.

  • EDs increasingly evolved into two distinct operations:

    • One for true emergencies (trauma, severe illness).

    • Another for urgent and primary care (for patients typically visiting a private physician or convenience facility).

  • Many hospitals now entirely separate ambulatory convenience care from the ED.

• Hospital-Built Freestanding Facilities: Hospitals and hospital corporations are building their own freestanding community-based convenience facilities.

• Ambulatory Surgery Departments/Centers: Hospitals are creating discrete ambulatory surgery departments within the hospital or building new freestanding ambulatory surgery centers.

• Impact on Design and Planning: The proliferation of both hospital-based and freestanding ambulatory services has created a more varied medical landscape for architects, designers, and planners. Innovative business relationships among hospitals, insurance providers, corporations, group practices, and individual physicians continue to drive demand for these facilities.

Medical Office Buildings (MOBs) and Physicians' Office Buildings (POBs)

• Traditional MOB/POB Design Limitations:

  • Historically, MOBs were designed primarily for solo practices.

  • They were not easily adaptable to larger single- and multispecialty group practices.

  • Shared central building support services (elevators, toilets, HVAC) were adequate for individual doctors but limited options for integrated group practice.

  • Rigid designs could not readily support sharing clinical areas (exam rooms, consultation, nurse support, procedure areas), diagnostics, reception, administrative services, and conference space.

• Design Criteria for Advanced MOBs (Patient-Focused):

  • Focus on Wellness: Must accommodate wellness services, fitness, and health maintenance, not just disease treatment.

  • Sophisticated Patients: Must appeal to today's more informed and discerning patients.

  • Universal Design: Incorporate elements for an aging patient population, including:

    • Lighting to eliminate glare.

    • Avoidance of strong contrasts.

    • Design to compensate for reduced color perception.

    • Furnishings that properly support an aging body.

    • Crystal-clear wayfinding cues.

  • Women-Centric Design: Design with women in mind, as they make most U.S. healthcare decisions, including family medical care choices.

• Consumer Model and Aesthetic Appeal:

  • Medical Mall Concept: The consumer and shopping metaphors are integrated into the "medical mall" concept.

  • Hospitals have renovated facilities into outpatient medical malls, or placed MOBs in suburbs as alternatives to busy medical campuses.

  • Avoiding "Formula Fast-Food Restaurant" Design: Jain Malkin, a medical interior designer, warns against generic design.

  • Value of Good Design: Retail merchants understand good design's marketing value. Aesthetically attractive and distinctive designs appeal to prospective patients, projecting an attitude of quality and excellence. This goes beyond mere appearance.

• Specialty-Specific Design Considerations:

  • Allergy Practice: Avoid heavily textured surfaces, shag rugs, or nubby upholstery (harborers of allergens).

  • Neurological Specialty: Avoid sharply contrasting surfaces, busy patterns, and vivid colors, which can exacerbate disorientation in neurologically afflicted patients.

  • Equipment Requirements: Certain specialties (e.g., MRI) require special design provisions for equipment, such as integrated shielding if the equipment is not self-shielded.

• Jain Malkin's Design Approaches: While hospitals follow a relatively small number of design approaches, Jain Malkin identifies nine distinct "gourmet recipes" for MOB design.