Developing & Designing Effective Ambulatory Facilities

Mar 14, 2014 at 12:00 am by Staff

The recession took a heavy toll on healthcare construction projects across the nation. However, as the economy has begun to improve, projects are beginning to move forward again. Experts in healthcare real estate development and evidence-based design recently shared their insights with Medical News regarding the current state of healthcare construction projects in the ambulatory setting.Real Estate DevelopmentAfter seeing a number of plans put on hold over the last few years, Bond Oman, chief executive officer of OGA, a national full-service real estate development and project management firm based in Nashville, said there has been an increase in activity lately. While dialysis projects have remained fairly steady throughout, he said, the improved financial environment has resulted in an uptick in ambulatory surgery centers, urgent care centers and behavioral health facilities, among other sectors.Oman said OGA presently has 21 projects in various stages of production. That is about a 30 percent increase over what the company was doing during the recession and quickly approaching pre-recession numbers, according to Oman. The company’s current portfolio includes work crossing the United States from California to Texas, Ohio to Florida.  One trend Oman said he is seeing nationwide is an emphasis on building smarter. He noted clients are trying to be more efficient by using basic green design to lower ongoing costs and keeping the building footprint as tight as possible. “With the health systems we are working with, we haven’t done a total gold or silver building,” he said, referring to Leadership in Energy and Environmental Design (LEED) status. However, Oman added, many employ green design when it comes to choosing lighting, insulation, windows, paint, and other elements that increase energy efficiency. In most cases, developers are still trying to strike a balance between the cost of adding green elements and the payoff in reduced monthly costs.As a whole, Oman said he thinks facilities are being built a little smaller on the front end but with room for growth. “We are designing a large number of our buildings for expansion,” he noted. Rather than creating facilities with shell space to be finished off later, Oman said he is really seeing more facilities completely finished but designed from the outset with the ability to blow out a wall for future outward expansion.What might be surprising to some is how quickly pricing has rebounded. Oman noted those considering developing healthcare properties aren’t going to find any real deals. “The cost of doing business is getting back to where it was pre-recession,” he noted. “I’d say we’re definitely going to see an increase in cost because the economy is doing better … not doing great but definitely doing a little better each year.”Oman noted landowners who survived the recession are holding firm on real estate prices. Many municipalities that dialed back or waived impact fees to try to entice developers a few years ago have reinstated, and in many cases increased, those fees. He said prices are also inching up for mechanical, electrical and plumbing. In general, Oman said healthcare development doesn’t tend to be speculative in nature. “It’s a different animal than a lot of the other real estate sectors,” he said, noting a demonstrated patient base and service need must be present before most in the medical industry will consider building. He added that while some markets — including Dallas, Denver, Houston and Nashville — are “on fire” right now, there is still a feeling of cautiousness across most of the nation. Still, projects that were halted a few years ago are beginning to get the green light again.An Evidence-Based Design AestheticWhere facilities are sprouting up, more and more of them are relying on research to inform design decisions. Ellen Taylor, AIA, MBA, EDAC, an architect for more than 25 years, began volunteering with the Center for Health Design (CHD) before she began working with the organization in 2008. As director of research, the New York-based Taylor helps spread the word about the best available information and latest credible research to help those creating healing spaces.“The Center for Health Design is a nonprofit based in California that looks at how the built environment can affect health outcomes … whether for the patient or staff,” she noted, adding CHD accomplishes this goal through research, education and advocacy.While elements of evidence-based design (EBD) have intuitively been incorporated in healing spaces for centuries, the formalized concept is relatively new. Taylor said a landmark 1984 study by Roger Ulrich, PhD — which found surgical patients with a view of nature had a reduced length of stay, required reduced levels of narcotics and had fewer complications — really captured people’s attention and launched the EBD movement. Since 2009, CHD has offered the Evidence-Based Design Accreditation (EDAC) to those who have proven their expertise in the field.Although launched in the acute setting, Taylor said an increased awareness of how design impacts outcomes and a focus in the Affordable Care Act on engaging patients and keeping them out of the hospital have combined to create a recognition that EDB has an important role in outpatient settings, as well. Another major trend for ambulatory spaces, she said, is the notion of flexibility and adaptability. It isn’t uncommon for one specialty to utilize a space two days a week with another specialty using it the rest of the time. “There’s this real need to be nimble,” Taylor said. “You can’t have a room that’s just designed for one purpose.”Taylor added the concept of the patient-centered medical home has really had an impact on facility design, as well. It is increasingly common to see outpatient clinics and facilities, particularly community health centers, include larger multipurpose rooms that could be used for a support group, to teach a health class or to hold neighborhood meetings. When working on safety net facility design in California, Taylor noted a center added a walking trail behind the facility so that a physician could prescribe ‘four loops’ to a patient in need of physical activity. To make it truly useful, a playground was installed in the center of the trail so parents could easily keep an eye on children, who coincidentally were also engaging in fun, physical activity playing outside. Similarly, some facilities have begun hosting a farmer’s market or have created a community garden and offer cooking classes to demonstrate the benefits of making simple, nutritious meals.Along the same vein, Taylor said it is becoming increasingly common for outpatient settings to be embedded in retail locations. Vanderbilt One Hundred Oaks in Nashville is an example of having mixed health and retail venues under one roof. Storefronts featuring supplies a patient needs to support a prescribed treatment sit next to national retailers featuring clothing or home goods. “It’s that concept of the one-stop-shop … if you can make it easier, you’ll have better compliance,” Taylor said.The Mayo Clinic, she continued, offers another example of innovative, flexible design. “They started realizing not everyone needed to disrobe for every appointment with physicians,” Taylor said. To address this, ‘Jack and Jill’ rooms were created — two offices with an exam room in between them. One patient could meet with his physician in the office, while another patient was using the exam room … or a patient might begin in the physician’s office and then move to the exam room to complete the appointment. “You have a more efficient flow,” Taylor pointed out. “You are freeing up that valuable exam space.”In addition to efficiency, however, Adelante Healthcare in Arizona is also studying whether or not the setup might also reduce stress levels and lead to increased patient satisfaction. Is it easier to pay attention and be more engaged in a conversation with a physician when fully clothed in an office compared to sitting on an exam table in a cold room while wearing a thin gown? Does the setting change patient behavior? Does the setup change outcomes? Finding quantifiable answers to those types of questions is key to EBD.Adelante is also studying other design tweaks that might shift the traditional power concept between physician and patient. Something as simple as having patients and physicians sit side-by-side and share a computer screen while discussing treatment options or giving a patient the ability to choose what they wish to view on a video monitor while waiting to see a provider can shift the perception of power. “That’s creating much more equality in care,” Taylor said. “There is a cultural awareness that needs to happen from a physician side, but then the design needs to accommodate that, as well.”Taylor concluded, “Ultimately what we hope is that the design of the built environment is one tool in the toolkit to improve outcomes and improve health overall.”

2014 Healthcare Design ConferenceWith a theme of “better care through better design,” the annual Healthcare Design (HCD) Conference is scheduled for Nov. 15-18, 2014 at the San Diego Convention Center in San Diego, Calif.The premier event devoted to how the design of responsibly built environments directly impacts the safety, operation, clinical outcomes, and financial success of healthcare facilities, the conference attracts architects, interior designers, top hospital and practice administrators, facility managers, healthcare construction professionals and researchers.For more information on the 2014 agenda or to register, go online to

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