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For many years the health care system has experienced a continuing decline in the number of beds required for inpatients. As inpatient care is reduced, there is a corresponding trend toward increased outpatient health care. An outpatient clinic is less expensive to build and operate than a hospital. Space need not be devoted to "hotel functions" (the typical nursing units of hospitals), and the extensive dietetic and housekeeping areas that accompany them. Fire code requirements are considerably less demanding and mechanical and electrical systems can be simpler. Multiple shifts of staff are not required, since the building is usually closed at nights and on weekends, and housekeeping can take place after it is closed to patients and most staff, rather than while it is occupied.
By definition, all outpatient facilities are alike in having no overnight patients. Otherwise, they can range from simple physicians' offices that provide primary care, to large, independent "hospitals without beds." Outpatient surgical facilities are now a common facility type, as the majority of surgical procedures may not require overnight hospitalization. An increasing number of community-level outpatient clinics are satellites of larger medical centers or systems, and are thus part of a complex that can emphasize continuity of care.
VA Outpatient Clinic, Springfield, MA
Almost all hospitals already include some outpatient diagnostic and treatment spaces. Many outpatient construction projects are responses to hospitals' increased outpatient workloads. Existing outpatient facilities within hospitals are expanded, overhauled, and updated. Such a renovation can serve a number of important functions in addition to that of giving the hospital a new outpatient focus. It may create improved circulation patterns or it may replace obsolete clinical areas with state-of-the-art services for use by inpatients as well as outpatients. Light-filled lobbies can give a friendly new face to hospitals that had been dour and intimidating-a new image that is very valuable in today's competitive climate.
Although outpatient facilities may vary greatly in size and in services offered, all should have certain common attributes:
Efficiency and Cost-Effectiveness
The layout of the clinic should:
- Group or combine functional areas with similar system requirements
Flexibility and Expandability
As medical needs, modes of treatment, and workload will continue to change, outpatient facilities should:
- Follow modular concepts of space planning and layout
- Use established standard room sizes and plans as much as possible, rather than tight and highly specific ones
- Be served by modular, easily accessed, and easily modified mechanical and electrical systems
- Where size and program allow, be designed on a modular system basis
- Be open-ended, with well planned directions for future expansion
Outpatient Clinic, VAMC Palo Alto, CA
Cleanliness and Sanitation
Both sanitation and the appearance of it are important goals for outpatient facilities. They are promoted by:
To encourage its use, the facility should be:
- Easy to find, clearly visible from the approach road, with good directional signage from nearby major roads
- Easy to recognize, with a welcoming image and clear, appropriately located directional signage
- Easy to enter, with visible, well-identified entrance, and a clear route from parking
All areas, both inside and out, should:
- Be easy to use by the many patients with temporary or permanent handicaps
Although the needs of outpatients are less intense than those of hospital inpatients, an individual's visit may still be very stressful. Every effort should be made to make the outpatient visit as unthreatening and comfortable as possible, and to make the patient's experience more like going to a doctor's office than to a hospital. This can be accomplished by:
- Ensuring entrance areas are designed to accommodate patients with slower adaptation rates to dark and light; marking glass walls and doors to make their presence obvious
Aesthetics is closely related to creating a therapeutic environment (homelike, attractive). Also, aesthetics is important to the clinic's public image and is thus an important marketing tool, both for patients and staff. Aesthetic considerations include:
- Use mechanical door openers to assist in entering and leaving the facility
In addition to general safety concerns of all buildings, clinics have several particular security concerns:
- Protection of clinic property and assets, including drugs
- Protection of patients, including incapacitated patients and staff
- Violent or unstable patients need to be controlled safely
- Large, prominent, publicly-owned clinics may be potential terrorism targets
Clinics are public buildings that have an impact on the environment and economy of the surrounding community. They are major users of energy and water and produce large amounts of waste. Because clinics place demands on community resources they are natural candidates for sustainable design.
Section 1.2 of VA's HVAC Design Manual is a good example of health care facility energy conservation standards that meet EPAct 2005 and Executive Order 13693 requirements. The Energy Independence and Security Act of 2007 (EISA) provides additional requirements for energy conservation. Also see LEED's (Leadership in Energy and Environmental Design) USGBC LEED for Healthcare.
The HIPAA (Health Insurance Portability and Accessibility Act of 1996) regulations address security and privacy of "protected health information" (PHI). These regulations put emphasis on acoustic and visual privacy, and may affect location and layout of workstations that handle medical records and other patient information, paper and electronic, as well as patient accommodations."
- A growing interest in more holistic, patient-centered treatment, which might include, among other things, the provision of a mini-medical/health care library and computer terminals, so patients can research their own conditions and treatments.
Relevant Codes and Standards
Code requirements for medical office buildings are much less restrictive than those for hospitals. Local building codes will largely govern. However, federal facilities on federal property generally need not follow local and state codes, but follow federal regulations.
Outpatient facilities operated under a hospital's license or requiring separate state licensing and accreditation will be governed by additional regulation. Many states base licensing on the AIA Guidelines for Design and Construction of Hospitals and Health Care Facilities, listed below as a resource, and thus that volume acquires regulatory status.
State and local building codes are based on the model International Building Code (IBC). Federal agencies are usually in compliance with the IBC except NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural Barriers Act Accessibility Guidelines (ABAAG) or GSA's ABA Accessibility Standards takes precedence.
Since clinics treat patients who are reimbursed under Medicare, they must also meet federal standards, and to be accredited, they must meet standards of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). Generally, the federal government and JCAHO refer to the National Fire Protection Association (NFPA) model fire codes, including Standards for Health Care Facilities (NFPA 99) and the Life Safety Code (NFPA 101).
The American with Disabilities Act (ADA) applies to all public facilities and greatly the building design with its general and specific accessibility requirements. The Architectural Barriers Act Accessibility Guidelines (ABAAG)
Federal agencies that build and operate outpatient clinics have developed detailed standards for the programming, design, and construction of their facilities. Many of these standards are applicable to the design of non-governmental facilities as well. Among them are:
- Department of Veterans Affairs(VA), Office of Construction & Facilities Management Technical Information Library contains many guides and standards, including:
- Design Guides for planning hospital based ambulatory care clinics, community based outpatient clinics, satellite outpatient clinics, and ambulatory surgery clinics. This information library also includes Design Manuals of technical requirements, equipment lists, master specifications, room finishes, space planning criteria, and standard details.
Products and Systems
See WBDG Health Care Facilities for generic health care facilities websites
- Design Details for Health: Making the Most of Design's Healing Potential, 2nd Edition by Cynthia A. Leibrock and Debra Harris. New York: John Wiley & Sons, Inc., 2011.-Innovative design solutions in key areas such as lighting, acoustics, color, and finishes
- Design Planning for Freestanding Ambulatory Care Facilities by Bill Rostenberg. Chicago: AHP, 1986.
- Emergency Department Design: A Practical Guide to Planning for the Future by John Huddy and Michael T. Rapp. Irving, TX: ACEP (American College of Emergency Physicians) 2000.
- Healthcare Facility Plannning: Thinking Strategically by Cynthia Hayward, AIA, FAAHC, ACHA. Health Admnistration Press and the American College of Healthcare Executives, 2005.
- Medical and Dental Space Planning: A Comprehensive Guide to Design, Equipment, and Clinical Procedures, 3rd Edition, by Jain Malkin. New York: John Wiley & Sons, Inc., 2002.
- Primary Health Care Centers by Martin Valins. Essex: Longman Group UK Ltd, 1993.
- Sound & Vibration: Design Guidelines for Health Care Facilities by the Acoustics Research Council. 2010.
- See WBDG Health Care Facilities for generic health care facilities publications
- SpaceMedGuide-A Space Planning Guide For Healthcare Facilities-a popular planning tool providing state-of-the-art planning methodologies, industry benchmarks, and planning tips.