8 Productivity Constraints that Could Be Hurting Your Medical Clinic

 

Medical clinics operating in today’s challenging reimbursement environment are trying to improve profitability by lowering cost per encounter and growing revenue. Reducing cost can only take a clinic so far; however, increasing revenue by producing more visits can offer a higher return on investment.

We believe that many existing medical clinics are hampered by design constraints that limit the number of visits. It has always been difficult to convince clinic leaders that new design will enable more visits without increasing staff or lengthening hours of operation. Nonetheless, architects are designing clinic spaces differently today and are experiencing better results.

We have identified 8 design features that restrict the productivity and efficiency of existing spaces. If your space has more than a few of these constraints, you might benefit from a re-design or re-location into a new space that can be designed to solve these problems. 
 
1.  Excessive Travel Distances

Excessive footsteps for providers and care team members can diminish productivity by adding unnecessary movements and wasting time. Studies show that the average provider only spends around 3% of their day in travel, but that still represents about 15 minutes of each 8-hour day. MAs and support staff spend even more of their day in route to the next task, which can contribute to further losses in provider productivity.

In poorly designed clinics, providers can travel as much as 300+ feet for each patient visit, which is about 1 minute of travel time. The following spaghetti diagram (the visual representation of the physical flow of people, materials, and papers) illustrates an inefficiently designed clinic with excessive travel distances:


 
High performance clinics are designed and planned to reduce foot travel. Spaghetti diagrams are analyzed to improve clinic flow and reduce travel distance and wait time. The resulting clinic spaces reduce provider travel to less than 30 feet per patient visit, and keep support staff under 50 feet.
 
The MGMA Healthcare Consulting Group suggests strapping on a pedometer and managing travel time as a key to success for physician group management. Here are some benchmarks for tracking your steps and comparing:

• Average person walks at a rate of 100 steps/minute
• Average walking stride is 2.5 feet/step
• Average physician spends 15 minutes/day in travel, which is the equivalent of 1,500 strides

2.  Separate Care Team and EMR Documentation Areas

Providers and MAs in most clinics spend a significant portion of their day on EMR documentation in separate areas, which creates unnecessary travel distances and other forms of waste. The average physician spends only 6% of their day in direct clinical face time with staff; increasing the frequency and quality of these interactions improves productivity. By co-locating the care team and EMR documentation areas, providers have more access to the care team, which increases efficiency and productivity in the following ways:
 
Communication Improved between Providers and MAs — Maximizing patient throughput requires a timely sequence of communication between providers and MAs. Some of these communications include:

• Room ready
• Patient history/vital sign particulars
• Need for supplies and equipment
• Need to set up rooms for special procedures
• Need to assist with medical examinations or procedures
• Medical orders
• Need for MA to perform treatments
• Need for MA to provide patient instructions

Co-locating care team and EMR documentation areas streamlines communication, reduces patient wait times, and increases throughput.
 
Search Eliminated for Providers or MAs — Proximity of care team and EMR documentation areas also eliminates wasted time searching for providers and MAs. Clinical flow is highly dependent on the flow of information. A single patient visit demands over a dozen exchanges of information between the patient, provider, and care team. In a typical clinic, this exchange of information occurs in three ways:

• Verbal — Direct face-to-face communication
• Visual — Visual signals such as the placement of colored flags or lights
• Electronic — EMR notifications or mobile notifications

Few providers rely solely on electronic and visual methods — face-to-face communication is imperative. Co-locating these spaces eliminates searching, which saves providers and MAs time and improves clinic flow.
 
MAs Leveraged to Reduce EMR Documentation Time — Delegating portions of EMR documentation to MAs and the support team can help boost provider productivity.
 
The following EMR administrative tasks can be done by MAs:

• Manage incoming messages with the provider during brief huddles between visits
• Manage incoming lab and radiology results
• Track labs for no-shows and cancellations
• Research refill requests

Co-locating EMR documentation and care team areas allows providers to assist the MAs with the documentation and provide ongoing feedback efficiently. Studies show providers spend significant time on EMR documentation (up to 37% of the provider’s day); reducing this burden can significantly improve provider productivity.  

3.  Lack of Visibility

The lack of 360-degree visibility from care team areas to the overall clinic negatively impacts productivity. The care team’s ability to understand and anticipate the needs and movements of providers, as well as patients, improves clinical flow. 360-degree visibility allows care team members to be aware of patient status and makes it easy for them to reach out to other care team members.
 
Flow transitions in many clinics are dependent on visual communication. Transitions that require verbal communications also require knowing where team members are located. Visibility to co-workers facilitates spontaneous and intentional communication, and contributes to greater awareness of operational habits and increases opportunities for knowledge sharing and process improvement.

Architects use space syntax methodologies to quantitatively calculate the visibility of spaces. These analytics have been applied to clinical environments and reveal more about a space than may be apparent when viewing a floor plan. Visibility analysis of case study clinics illustrates the visual affordance (how much of the space can be seen from a certain point) of care team area location and configuration. The location and size of high visibility zones (indicated in red) is where most of the team communication occurs, which should align with the care team area location.
 

 
When alignment occurs between high visibility zones and the care team area location, the following benefits are realized:

• Connectedness between care team and providers
• Increased problem solving abilities
• Higher rate of process improvement
• Greater productivity

The key is creating visibility from the team area to all areas of travel in the work flow with the right mix of spaces based on the communication, work, and collaboration that needs to occur.

4.  Inflexible Work Surfaces and Work Station Configurations

Research on clinicians found that most provider and MA tasks in care team areas are short, typically two minutes or less. In fact, caregivers were more frequently observed standing to do tasks than seated. Unfortunately, most work areas are designed for seated desk work. This design forces providers to work bent over a seated-height work surface when they have only a brief task to complete and are reluctant to take the time to sit.
 
In response, furniture designers have been researching and developing new models of multi-faceted workstations that allow for seated or standing work height. A variety of different desktop configurations, counters, and interactive tables can accommodate the needs of providers and their clinical support teams.
 
Perching workstations with digital EMR monitors that can be viewed by providers and MAs together increase situational awareness and unplanned casual interactions. Universal sit stations accommodate a variety of staff roles and provide balanced ratios of collaborative vs. heads-down work. The ability to work and complete tasks in a flexible environment allows providers to be more productive than their counterparts who work from dedicated rooms.
 
5.  Centralized vs. Decentralized Supplies

Many clinics do not have supplies and equipment properly distributed for daily use. The question of what supplies and equipment to centralize vs. decentralize is a matter of saving time vs. cost of duplication and stocking. The design of clinic storage spaces often prohibits the ideal flow of daily materials and equipment. Time spent working around these inefficiencies is wasted productivity. 
 
Decentralized Storage — High frequency use items should be decentralized and uniformly distributed. Having a standardized method for storing, counting, and picking supplies, and then distributing to cupboards, carts, and bins, should not be left to random methods. Highly efficient clinics have a standard place for high frequency use items. The design and location of equipment, cupboards, shelves, drawers, and cart alcoves should be uniform across all exam rooms and work areas. This creates predictability and improves productivity.
 
Centralized Storage — Low frequency use items and expensive rolling equipment that demand minimal use should be centrally located for access. Too often this equipment ends up in ad hoc locations that are not convenient for access. Productivity erodes when equipment and supplies cannot be quickly located. The design of highly visible storage alcoves for equipment allows care team members to quickly identify if equipment is in use.
 
The design of storage spaces should support the proper flow and usage of equipment and supplies. The following factors should be considered:

• Accountability and control 
• Inventory visibility
• Simple manual processes
• Standard work processes

6.  Non-Standardized Exam Rooms

Exam rooms are the key space where clinical care is delivered. Non-standardized exam rooms slow provider workflows and create waste. As a result, the design community has placed a large emphasis on studying the design of these rooms. Many key findings have been implemented and tested over the last decade. Chances are your current exam rooms are a hindrance to productivity.
 
The first imperative for exam room design is standardization. This concept is often referred to as “same-handed” rooms. In other words, all exam rooms are designed exactly the same, with all features, doors, furniture, and fixtures in exactly the same location. This allows providers to know exactly where things are and to develop standardized movements and processes in daily routines. Standardization not only improves productivity but also allows providers to focus on higher level thought processes, rather than having to recall the differences between various locations of items between exam rooms. 
 
Other key concepts in exam room design include the following:

• Universal Rooms — Exam rooms designed for use by all specialties and provider types, allowing for flexible use of rooms to improve scheduling and room utilization
• Zoned Rooms — Exam rooms designed with distinct zones for patients, family, and care providers that do not overlap
• Technology Integration — Incorporating new and emerging technology into exam rooms to promote the transfer of knowledge between caregivers, patients, and family in an arrangement that keeps providers facing patients.

7.  Small Exam Rooms

Improving productivity depends on even flow and predictability and not solely on eliminating waste. In clinics that have a variety of exam room sizes and differing configurations due to building column spacing and other irregularities in design, constraints are placed on exam room usage, especially when rooms are too small.

There are many theories on exam room size, but leading healthcare designers who have rigorously studied the subject agree that 10 feet x 11 feet is the ideal size for single-door exam rooms. These dimensions benefit the care team and patient by allowing for:

• Space Intensive Exam Protocols — Exam protocols that require access to the patient from all sides or involve additional equipment
• Unconflicted Work Area — Clear provider work zone that does not overlap with family members and patient items
• Companion Space — Separated space for patient companions
• Patient Access (including Bariatric Patients) — Access and maneuverability for wheelchairs, walkers, and other DME required to facilitate patients needs

If your clinic has small exam rooms that are impractical for certain situations, you may be forced to wait for larger rooms to open, which creates bottlenecks. Holding dedicated rooms open to accommodate the specific requirements for these exam conditions and patient needs can also disrupt clinic flow. The unexpected need for additional space for any variety of needs can be a major disruption in throughput, as the care team scrambles to find open space in larger exam rooms. With all exam rooms sized appropriately, predictability and even flow can contribute to productivity.
 
8.  No Space for Confidential Communications

Balancing productivity and confidentiality is a difficult task for providers who operate in spaces that are not designed for the task. This problem is compounded by the fact that clinical flow is dependent on so much verbal and visual communication. Providers and MAs have developed many workarounds, including signals and code words to aid in the protection of confidentiality.
 
Time is wasted and flow disrupted when providers and care team members must move to confidential rooms to have routine conversations. However, high performance clinic designs isolate provider and care team areas from common corridors and public areas so communications can take place freely and efficiently. There are a variety of design concepts that incorporate these benefits and allow for 360-degree visibility.
 
Conclusion:  Putting It All Together

Improving productivity and producing more patient visits per day can offer a higher return on investment than simply cutting costs. While clinic design seems like a far-reaching concept toward improving productivity, consider the additive effect of eliminating three to five of the design constraints discussed.
 
If providers can pick up a modest 2-3 minutes per patient visit consistently by eliminating wasted time and leveling flow, they could achieve considerable patient volume increases over the year. A daily increase of two patient visits per provider multiplied by the number of providers in your clinic will contribute to a significant increase in net revenue year over year.

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