This article was downloaded by: [University of Montana] On: 04 April 2015, At: 20:39 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Programming and Design of Hospital Ambulatory Care Facilities Ronald L. Skaggs A.I.A.
a
a
Health Care Facilities , Harwood K. Smith & Partners, Inc. , USA Published online: 13 Jul 2010.
To cite this article: Ronald L. Skaggs A.I.A. (1977) Programming and Design of Hospital Ambulatory Care Facilities, Hospital Topics, 55:4, 42-44, DOI: 10.1080/00185868.1977.9950415 To link to this article: http://dx.doi.org/10.1080/00185868.1977.9950415
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
PROORAMMINO AND DES10N OF HOSPITAL AMBULATORY CARE FACILITIES BY RONALD L. SKAGGS, A.I.A. Vice President, Health Care Facilities Harwood K. Smith & Partners, Inc.
-
Downloaded by [University of Montana] at 20:39 04 April 2015
Ambulatory Care A Conitruction Priority
Rondd L. Skaggs, a principal and health specialkt at Harwood K. Smith & Partners Inc., earned his Masters degree in Health Facilities Planning and Research from Texas A&M Uniwrsiw. Since then he has been active& engaged in the design of o w fijty health and health d a t e d institutions induding hmpitals, clinics, mental healthfacilities, and medical and dental schools. Formedy a health facilities officer with the U.S Army Office o f t h e S u r p n General, Ron worked with the facilities branch in progmmmingand design concept development of Army medical facilities including hospitals ranging in size from 100 to 1,200 beds He has worked with vduntay, proprietary ond governmentclientgroupsandis wrsedon specificneedsofeach. He is a Corporate Member, American Institute of Architects, Texas Society of Architects; Member, Committee on Architecturn for Health, Dellas Chapter, American Institute of Architects, Member, AHA, Member, American Association for Haspital Planning. He has contributed to the literature and has been a faulty member of many Institutes.
tatistics indicate that over the last two decades there has been a staggering increase in emergency and hospital outpatient visits resulting in a change from 2.3 visits per hospital admission to 5.6 visits. During the first half of the 1970’s, inpatient admissions have increased around 15%; whereas, outpatient visits have increased moE than 55%.
S
42
The development of ambulatory oriented facili~eshas become a major construction priority in our nation. There are demands from all segments of our society for improved access to efficient cost effective health care. Most people agree that a national health insurance program is extremely likely to be established by the end of this decade. No matter what form such a program takes, it can be expected to provide additional impetus to the consumer for the utilization of ambulatory care facilities, as expressed in England, and within the American military medicine system. In recent years there has been a shifting emphasis by government, public and private interests from inpatient to outpatient facilities. An overriding philosophy in the development of ambulatory care facilities is the provision of a uniform level of primary care in a pattern equal to that of private group practice. A primary task of the architect then is simulating the best aspects of private doctors offices in the context of an institutionally oriented ambulatory care center. Primary ambulatory care covers a wide spectrum including health maintenance, preventive care, emergency care, patient screening and appropriate diagnosis and treatment of patient illness. An ideal system of ambulatory care might include: 1. easy accessibility: financial&, gwgraphically v d ondemand; 2. comprehensiw care: prodding complete prima y services with mferred back-up for secondary and tertiary levels of care: and 3. continuid of care: to avoid episodic and uncontrolled development of illness by establishing personalized patient relationship with concernfor the patient’s total milieu.
University Medical Center: major university medical centers have traditionally operated large ambulant patient clinics as part of the medical student’s academic program. The majority of these facilities consist of a variety of specialty clinics not conducive to the delivery of primary continuing medical care. Medical educators are placing more HOSPITAL TOPICS
emphasis on clinically oriented teaching where the student can learn in a “real world’’ environment. Some medical schools have placed specialty clinics in ambulatory care buildings with clinics located adjacent to faculty offices, clinical research and service related teaching beds.
Downloaded by [University of Montana] at 20:39 04 April 2015
Hospital Bemed Ambulatory Care Centers There is an increasing public awareness and confidence in the hospital as the appropriate place to obtain all medical care around the clock. Hospital based ambulatory care centers afford the primary level care to the patient with immediate access to various specialists for consultation and to the hospital ancillary departments such as radiology and pathology for diagnostic and treatment. Community hospitals are becoming a major provider of care to the ambulant patient, for years federally operated hospitals: for example, Military, Public Health Service and V.A., have successfully provided ambulatory care in clinics that are adjuncts to the hospital. In planning hospital oriented ambulatory care centers it should be remembered that outpatients use many parts of the hospital and it is desirable to develop Diagnostic & Treatment functions such as radiology, laboratory, surgery, emergency, respiratory therapy, electrodiagnostics and physical therapy as an interface between the ambulatory and inpatient functions. Hospital based ambulatory care centers have the added benefit of receiving support from various hospital services including central services, dietary services, maintenance, housekeeping and medical records.
Specialty Ambulatory Centera A variety of specialized ambulatory facilities are being developed, often as freestanding units. Surgicenters providing one day surgery on an outpatient basis, multiphasic screening centers providing automated physical exams, renal dialysis centers for outpatient use by kidney patients are examples of these kinds of facilities. The variability in kinds of settings for care of the ambulant patient does not permit a single answer to the development of facilities, and the planning process requires great care in identifying the unique program requirements inherent in each individual project. JU LY/AUG UST 1977
DevelopingA Facilities Program Although the impulse often is to build immediately, it is important that adequate time be spent prior to the actual development of plans. There is often a tendency to build before program components are clearly defined resulting in facilities that are not responsive to the real needs of the community served. The ambulatory care facility development process should begin with establishment of a nucleus team of users and planners working together through the following phases of development: Master Hanning: determining and defining xwices, objectives an dpmject feasibility. Programming: establishing and quantifying thefunctional nequirements necessary to accomplkh the defined objectiws. Design: architectural development of defined functional requirements into physical space, an d Construction: building o/ the phyGcal space according to the architecturalplansan dspecifications
Planning and programming are often a combined effort, the final results of which serve as the guide for design of the ambulatory care center. Early in the planning process population characteristics and trends must be assessed as they relate to the community the facility is to serve. Transportation to and from the facility should be analyzed in an effort to make the facility as accessible for the community as possible. The nature and location of other facilities in the area and their affect on the proposed facility require consideration. Unmet needs and new services to be provided must be determined and balanced with the health manpower resources available. An overlying factor in the early planning phase is the role of the ambulatory care facility is to play in the overall health system and what emphasis beyond its patient care role will be placed on education and research. Performance of a financial feasibility study during the early planning stages can reap great rewards down the line. No one wants to build more than they can afford: on the other hand it can be as great a mistake, because of a limited knowledge of available funding, to design less than is really needed and later discover that more could have been afforded. After the master plan is solidified the architectural program can be developed. As mentioned previously, program development should be the result of joint activity between the facility team and the design team. Drawing from planning objectives already identified, various programming criteria must be applied to projected workload patterns in order to
43
develop a detailed listing of spaces and functional relationships to satisfy desired patterns of operation. In order to project these facility requirements, it is important that hours and days of clinic utilization be determined with thought to the fact that many patients are unable to see a doctor during regular working hours. Clinic schedules must be established taking into account patient load and length of visit by specialty, Patients might visit the facility by a variety of methods including:
Downloaded by [University of Montana] at 20:39 04 April 2015
(1) thefimt time visit requiring initial medical hisrory andfull physical (2) appointment care (3) non-appointment walk-ins 14) 4 t e r hours care and f5) scheduled specialty diagnosis and treatment such as laboratory, x-ray and electrocardiogram procedures.
Therefore, great care is required in analyzing where and in what manner different kinds of visits will be handled. The facilities program must identify the operational structure of the ambulatory care center. If the facility is to be only primary care oriented, is it to consist of a series of group practice clusters made-up of a variety of specialists, or is it to consist of family practice units that refer to separate specialty units in the clinic? Are non-medical services such as dentistry, social service, podiatry, mental health and family planning to be provided? Is the facility to include support services such as laboratory, radiology and pharmacy or will these functions be shared with the hospital?
Is the emergency department to be adjunct to the ambulatory care center, and will outpatient surgery be provided here or in the main surgical suite? Will there be a central clinic administration and medical records activity or will these functions be co-located with the hospital's administrative area? An Ambulatory Care Center can be structured in a variety of ways. As an example, a hospital based ambulatory care center might be organized in the following manner: Public Functions: bbby, general waiting, conference, daycarefacilities andsimilar functions. Adminktratiw Services: clinic registration, business office, medical recorrls and related functions. Clinic Modules: modular clusters for famib care and specialty care. Non-Medical Health Services: optometry, social work, nutrition, health education, rehabilitation. satellite pharmacy, satellite laboratory and related functions.
44
Diagnostic and Treatment Sem'ces: (possibly shared with the hospital) laboratory, radiology. physical medicine, outpatient surgery, emergency care, electrodiagnostics and related functions. Support Services: (possibly provided by the limpitall supply, housekeeping, security, maintenance, waste disposal and related services.
Design For Flexibility After the facility program is completed the process of translating the defined needs into plans for construction can begin. Consideration should be given to providing easy access into the ambulatory care center. An inviting entrance into an identifiable reception point, so arranged that the patient is clearly oriented to the organization of the center, is important. Waiting areas should be humanistic and individualistic and preferrably decentralized as part of each clinic cluster, similar to the environment in a private physicians' office. Attention must be given to developing clinic units to a scale that reflects comfortable noninstitutional family oriented care rather than the overbearing largeness experienced in many outpatient clinics. Pleasing colors and textures do much to provide an environment that is comfortable and reassuring. For maximum clinic utilization it is ideal to provide flexible facilities that can be adapted easily. The majority of clinic activities require examining and treatment rooms of the same general type. Special purpose rooms can be assigned in zones planned to accommodate unique space and equipment requirements. The grouping of fixed elements in a manner that permits large open space will allow easy rearrangement of internal space when required. Rooms should be designed as convertible, multi-use space to allow easy mix and change in patient utilization. Ambulatory care facilities can expect to experience expanding and changing roles in the future. Modular structures with ability to flex with the minimum disruption of existing operations as more space is required, are particularly applicable in the development of ambulatory care facilities. Flexible loft type space with fixed elements placed incrementally outside of long open spans is now commonplace, and today's building systems and components permit greater interior adaptability. Modular mechanical and lighting systems and relocatable walls and cabinetry lend to easy rearrangement in order to respond to varying organizational patterns whether they be group practice, family practice clusters, specialty clinics or screening clinics. HOSPITAL TOPICS
Hospital Topics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vhos20
Programming and Design of Hospital Ambulatory Care Facilities Ronald L. Skaggs A.I.A.
a
a
Health Care Facilities , Harwood K. Smith & Partners, Inc. , USA Published online: 13 Jul 2010.
To cite this article: Ronald L. Skaggs A.I.A. (1977) Programming and Design of Hospital Ambulatory Care Facilities, Hospital Topics, 55:4, 42-44, DOI: 10.1080/00185868.1977.9950415 To link to this article: http://dx.doi.org/10.1080/00185868.1977.9950415
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
PROORAMMINO AND DES10N OF HOSPITAL AMBULATORY CARE FACILITIES BY RONALD L. SKAGGS, A.I.A. Vice President, Health Care Facilities Harwood K. Smith & Partners, Inc.
-
Downloaded by [University of Montana] at 20:39 04 April 2015
Ambulatory Care A Conitruction Priority
Rondd L. Skaggs, a principal and health specialkt at Harwood K. Smith & Partners Inc., earned his Masters degree in Health Facilities Planning and Research from Texas A&M Uniwrsiw. Since then he has been active& engaged in the design of o w fijty health and health d a t e d institutions induding hmpitals, clinics, mental healthfacilities, and medical and dental schools. Formedy a health facilities officer with the U.S Army Office o f t h e S u r p n General, Ron worked with the facilities branch in progmmmingand design concept development of Army medical facilities including hospitals ranging in size from 100 to 1,200 beds He has worked with vduntay, proprietary ond governmentclientgroupsandis wrsedon specificneedsofeach. He is a Corporate Member, American Institute of Architects, Texas Society of Architects; Member, Committee on Architecturn for Health, Dellas Chapter, American Institute of Architects, Member, AHA, Member, American Association for Haspital Planning. He has contributed to the literature and has been a faulty member of many Institutes.
tatistics indicate that over the last two decades there has been a staggering increase in emergency and hospital outpatient visits resulting in a change from 2.3 visits per hospital admission to 5.6 visits. During the first half of the 1970’s, inpatient admissions have increased around 15%; whereas, outpatient visits have increased moE than 55%.
S
42
The development of ambulatory oriented facili~eshas become a major construction priority in our nation. There are demands from all segments of our society for improved access to efficient cost effective health care. Most people agree that a national health insurance program is extremely likely to be established by the end of this decade. No matter what form such a program takes, it can be expected to provide additional impetus to the consumer for the utilization of ambulatory care facilities, as expressed in England, and within the American military medicine system. In recent years there has been a shifting emphasis by government, public and private interests from inpatient to outpatient facilities. An overriding philosophy in the development of ambulatory care facilities is the provision of a uniform level of primary care in a pattern equal to that of private group practice. A primary task of the architect then is simulating the best aspects of private doctors offices in the context of an institutionally oriented ambulatory care center. Primary ambulatory care covers a wide spectrum including health maintenance, preventive care, emergency care, patient screening and appropriate diagnosis and treatment of patient illness. An ideal system of ambulatory care might include: 1. easy accessibility: financial&, gwgraphically v d ondemand; 2. comprehensiw care: prodding complete prima y services with mferred back-up for secondary and tertiary levels of care: and 3. continuid of care: to avoid episodic and uncontrolled development of illness by establishing personalized patient relationship with concernfor the patient’s total milieu.
University Medical Center: major university medical centers have traditionally operated large ambulant patient clinics as part of the medical student’s academic program. The majority of these facilities consist of a variety of specialty clinics not conducive to the delivery of primary continuing medical care. Medical educators are placing more HOSPITAL TOPICS
emphasis on clinically oriented teaching where the student can learn in a “real world’’ environment. Some medical schools have placed specialty clinics in ambulatory care buildings with clinics located adjacent to faculty offices, clinical research and service related teaching beds.
Downloaded by [University of Montana] at 20:39 04 April 2015
Hospital Bemed Ambulatory Care Centers There is an increasing public awareness and confidence in the hospital as the appropriate place to obtain all medical care around the clock. Hospital based ambulatory care centers afford the primary level care to the patient with immediate access to various specialists for consultation and to the hospital ancillary departments such as radiology and pathology for diagnostic and treatment. Community hospitals are becoming a major provider of care to the ambulant patient, for years federally operated hospitals: for example, Military, Public Health Service and V.A., have successfully provided ambulatory care in clinics that are adjuncts to the hospital. In planning hospital oriented ambulatory care centers it should be remembered that outpatients use many parts of the hospital and it is desirable to develop Diagnostic & Treatment functions such as radiology, laboratory, surgery, emergency, respiratory therapy, electrodiagnostics and physical therapy as an interface between the ambulatory and inpatient functions. Hospital based ambulatory care centers have the added benefit of receiving support from various hospital services including central services, dietary services, maintenance, housekeeping and medical records.
Specialty Ambulatory Centera A variety of specialized ambulatory facilities are being developed, often as freestanding units. Surgicenters providing one day surgery on an outpatient basis, multiphasic screening centers providing automated physical exams, renal dialysis centers for outpatient use by kidney patients are examples of these kinds of facilities. The variability in kinds of settings for care of the ambulant patient does not permit a single answer to the development of facilities, and the planning process requires great care in identifying the unique program requirements inherent in each individual project. JU LY/AUG UST 1977
DevelopingA Facilities Program Although the impulse often is to build immediately, it is important that adequate time be spent prior to the actual development of plans. There is often a tendency to build before program components are clearly defined resulting in facilities that are not responsive to the real needs of the community served. The ambulatory care facility development process should begin with establishment of a nucleus team of users and planners working together through the following phases of development: Master Hanning: determining and defining xwices, objectives an dpmject feasibility. Programming: establishing and quantifying thefunctional nequirements necessary to accomplkh the defined objectiws. Design: architectural development of defined functional requirements into physical space, an d Construction: building o/ the phyGcal space according to the architecturalplansan dspecifications
Planning and programming are often a combined effort, the final results of which serve as the guide for design of the ambulatory care center. Early in the planning process population characteristics and trends must be assessed as they relate to the community the facility is to serve. Transportation to and from the facility should be analyzed in an effort to make the facility as accessible for the community as possible. The nature and location of other facilities in the area and their affect on the proposed facility require consideration. Unmet needs and new services to be provided must be determined and balanced with the health manpower resources available. An overlying factor in the early planning phase is the role of the ambulatory care facility is to play in the overall health system and what emphasis beyond its patient care role will be placed on education and research. Performance of a financial feasibility study during the early planning stages can reap great rewards down the line. No one wants to build more than they can afford: on the other hand it can be as great a mistake, because of a limited knowledge of available funding, to design less than is really needed and later discover that more could have been afforded. After the master plan is solidified the architectural program can be developed. As mentioned previously, program development should be the result of joint activity between the facility team and the design team. Drawing from planning objectives already identified, various programming criteria must be applied to projected workload patterns in order to
43
develop a detailed listing of spaces and functional relationships to satisfy desired patterns of operation. In order to project these facility requirements, it is important that hours and days of clinic utilization be determined with thought to the fact that many patients are unable to see a doctor during regular working hours. Clinic schedules must be established taking into account patient load and length of visit by specialty, Patients might visit the facility by a variety of methods including:
Downloaded by [University of Montana] at 20:39 04 April 2015
(1) thefimt time visit requiring initial medical hisrory andfull physical (2) appointment care (3) non-appointment walk-ins 14) 4 t e r hours care and f5) scheduled specialty diagnosis and treatment such as laboratory, x-ray and electrocardiogram procedures.
Therefore, great care is required in analyzing where and in what manner different kinds of visits will be handled. The facilities program must identify the operational structure of the ambulatory care center. If the facility is to be only primary care oriented, is it to consist of a series of group practice clusters made-up of a variety of specialists, or is it to consist of family practice units that refer to separate specialty units in the clinic? Are non-medical services such as dentistry, social service, podiatry, mental health and family planning to be provided? Is the facility to include support services such as laboratory, radiology and pharmacy or will these functions be shared with the hospital?
Is the emergency department to be adjunct to the ambulatory care center, and will outpatient surgery be provided here or in the main surgical suite? Will there be a central clinic administration and medical records activity or will these functions be co-located with the hospital's administrative area? An Ambulatory Care Center can be structured in a variety of ways. As an example, a hospital based ambulatory care center might be organized in the following manner: Public Functions: bbby, general waiting, conference, daycarefacilities andsimilar functions. Adminktratiw Services: clinic registration, business office, medical recorrls and related functions. Clinic Modules: modular clusters for famib care and specialty care. Non-Medical Health Services: optometry, social work, nutrition, health education, rehabilitation. satellite pharmacy, satellite laboratory and related functions.
44
Diagnostic and Treatment Sem'ces: (possibly shared with the hospital) laboratory, radiology. physical medicine, outpatient surgery, emergency care, electrodiagnostics and related functions. Support Services: (possibly provided by the limpitall supply, housekeeping, security, maintenance, waste disposal and related services.
Design For Flexibility After the facility program is completed the process of translating the defined needs into plans for construction can begin. Consideration should be given to providing easy access into the ambulatory care center. An inviting entrance into an identifiable reception point, so arranged that the patient is clearly oriented to the organization of the center, is important. Waiting areas should be humanistic and individualistic and preferrably decentralized as part of each clinic cluster, similar to the environment in a private physicians' office. Attention must be given to developing clinic units to a scale that reflects comfortable noninstitutional family oriented care rather than the overbearing largeness experienced in many outpatient clinics. Pleasing colors and textures do much to provide an environment that is comfortable and reassuring. For maximum clinic utilization it is ideal to provide flexible facilities that can be adapted easily. The majority of clinic activities require examining and treatment rooms of the same general type. Special purpose rooms can be assigned in zones planned to accommodate unique space and equipment requirements. The grouping of fixed elements in a manner that permits large open space will allow easy rearrangement of internal space when required. Rooms should be designed as convertible, multi-use space to allow easy mix and change in patient utilization. Ambulatory care facilities can expect to experience expanding and changing roles in the future. Modular structures with ability to flex with the minimum disruption of existing operations as more space is required, are particularly applicable in the development of ambulatory care facilities. Flexible loft type space with fixed elements placed incrementally outside of long open spans is now commonplace, and today's building systems and components permit greater interior adaptability. Modular mechanical and lighting systems and relocatable walls and cabinetry lend to easy rearrangement in order to respond to varying organizational patterns whether they be group practice, family practice clusters, specialty clinics or screening clinics. HOSPITAL TOPICS
