arch7130_retail medical clinics_fall2014

innovations in healthcare

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RETAIL MEDICAL CLINICSNortheastern University School of Architecture

ARCH 6330 Masters Research Studio - Fall 2014

2RETAIL MEDICAL CLINICS

RETAIL MEDICAL CLINICSNortheastern University School of Architecture

ARCH 6330 Masters Research Studio - Fall 2014

PREFACEOver a 10-week period, 13 graduate students in Northeastern Universitys Graduate Program of Architecture analyzed new and emerging models of primary care facilities, focusing specifically on the development of retail medical clinics. The class objective is to thoroughly understand the history, operations, and potentials of the retail medical clinic in the broader landscape of health care services.

Created in collaboration with the design and management teams of the CVS Health MinuteClinic, the research is aimed at identifying possibilities for improved clinic models. Through an understanding of the successes and failures of the existing facilities and the ways in which design can play a role in improving the experience of caregivers and patients, we can establish a better understanding of how design can positively impact and respond to evolving modes of health care delivery.

This effort is the second in a multi-year effort to explore the role of design and architecture in health care. Unlike the previous years research, which provided a quantitative overview of primary care venues generally, this document goes into greater depth on hybridized programs such as retail medical clinics. The group has emphasized qualitative aspects, including spatial analysis of the exam room, experiences related to the waiting room, branded environments, and certain program boundaries to lead to ideas for future innovation in retail medical clinics.

innovations in healthcare

ACKNOWLEDGEMENTS

Colin GastJessica CooperLaurel ClarkRebecca SmithVictoria WiegandZahidah AlzainDeema ElmoisheerCarol GoforthMeghan DoranHeather GIllamZhongmei CaoSara Al-OtaibiJohn Hayford

RESEARCH TEAM

Matthew LittellGeorge ThrushJordan Goldstein

FACULTY / ADVISERS

We would like to thank the following people and companies for their generous contribution of time, knowledge, and resources:

Christina SprowsStephanie SznekeMike LePageNeil VecchiarelliChristine SawickiNeil KeislingNini SilvaDan KerlsLiz BoothBen SprowsDebra Hoffsman (NP)Lori Phinney (NP)

CVS Health HEALTH

TABLE OF CONTENTSTHE CLINIC retail clinic 12target markets 20scope of services 26 HOW + WHERE CARE HAPPENS exam room functionality 34 telemedicine 60infusion therapy 70

WAITING + PRIVACY psychology + magementment tactics 82precedents 94variables to consider 108identifying patterns 136

BRAND + PLACEMAKING + ENVIRONMENTS brand blend 166interior environment design 190graphic design + wayfinding 220

USER EXPERIENCES user types 258caregiver experience 260patient experience 250

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2

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4

5

6

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PROGRAM BOUNDARIES boundary types + elements 298precedent studies 310

metrics 364

BUSINESS DEPLOYMENT alternative retail experiences 370components of CVS Health 378types of CVS Health 382examples of prototypes 390

layout analysis 398

APPENDIXsustainability 408

SOURCES

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9

9

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THE CLINIC

retail medical clinicstarget market

scope of diagnostics

122026

THE RETAIL CLINIC

With new health care and health insurance changes, the way in which we receive care is leading towards retail medical clinics. This section will explain the dynamics of a retail medical clinic including what it is, their recent rapid growth and their target markets.

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WHAT IS A RETAIL CLINIC?

the clinic / retail clinic

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A retail medical clinic, or convenient care clinic (CCC), is a type of walk-in clinic which offers a variety of health care services within common retail store environments. The aim of the retail medical clinic is to help people of average health get convenient and quality health care when needed. Therefore, retail medical clinics are often open 7 days a week (including weekends), require no appointment and are often more cost efficient when compared to primary care or hospital visits.

Some advantages to using retail medical clinics include:- Guaranteed appointment times- Short consultations- Convenient locations + hours- Up front pricing- Lower prices than ER and urgent care- Cash or insurance payments accepted- Electronic health record available

Some disadvantages include: - Short consultation (may not leave much time to explain health history, details of current complaint)- Detract from development of a medical home and relationship with primary care doctor- Limited set of conditions treated- May miss important follow up care required from certain conditions- Oversight of clinics varies from state to state- Usually not treated by an M.D.

4 Major Clinics

3 Major Clinics

2 Major Clinics

1 Major Clinic

States with Major Clinic Locations

Retail medical clinics are located in common pharmacy and retail stores such as CVS Health, Target, Walmart, Walgreens and various other stores which have the capacity to offer medical care needs. On the right is a series of maps which show states with major retail medical clinic as of 2014, in addition to a map which shows which states contain frequent locations.

retail medical clinics

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CVS Health Clinic

Target Clinic

Walgreens Clinic

Walmart Clinic

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RETAIL CLINIC GROWTHAs health care reform has produced a sudden increase in newly insured people seeking care, and the ratio of elderly to young continues to rise, the health care system struggles to keep up with the challenge of providing an adequate amount of health care facilities to provide the necessary services that meet the current demands. One of the answers to the health care issue was the rapid growth of the retail medical clinic. The addition of many retail clinic act as a tool within the health care system through their ability to manage the volume of patients while more conventional health providers focus on higher acuity and more complex treatments, and programs like population health management and telemedicine.

Accenture Research has projected that, between 2012 and 2015, the number of health care clinics will grow between 25% and 30% annually. This impacts the number of retail medical clinics by nearly double, increasing the number of current clinics to nearly 2,800. This will allow the clinics to take on nearly 10.8 million visits per year that hospitals and primary care facilities currently cannot fill, and save approximately $800 million per year in health care expenditures through the use retail clinics which are able to provide the same care at more cost efficient prices.



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500%

400%

300%

200%

100%

0%2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

100%

50% 56%71%

442%

170%157%

30%

1% 3%11%

5%25+ %

30+ % 30+ %

Retail Medical Clinics Percent of Growth, 2001 to 2015

Since the beginning of the rapid growth of retail medical clinics in 2000, the number of clinics has continually increased each year. The graph above compares the percent of the increase of retail clinics by year between 2001 and then projected until 2015. As you can see, there have been years where there was a large amount of growth (up to 442%) compared to some others which appear to be have a low increase in number (as low as 1%). However, to put it into perspective, a 1% increase within a year can equal approximately 280 additional clinics. While there are many reasons for the growth of retail clinics, one which has changed the demand for health care services was the

addition of the Patient Protection and Affordable Care Act which went into effect as of 2010. This act was intended to increase the quality and affordability of health insurance, lower uninsured rates by expanding public and private insurance coverage, and reduce costs of health care for individuals and the government. This meant that the number of clinics had to increase again in order to try to meet the demands of the additional patients now seeking health care.

Year

Percent of Growth

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CVS HEALTH MINUTECLINIC GROWTH

CVS Health is one of the pioneers in the retail health care industry and continues to be the leading example of retail clinics. CVS Healths MinuteClinic is an interesting alternative for various health care services. The company expects to operate 1,000 MinuteClinics by 2016, as well as place a MinuteClinic in every state that has a CVS Health/pharmacy location. MinuteClinic facilities are constantly opening in new locations, both renovated into existing stores and built into new stores Above is a line graph which shows the rate in which MinuteClinics have increased throughout the United States. As you can see, they had most of their growth in the early years (2006-2008) but continue to grow into the future.

The map on the right shows locations of MinuteClinics within Massachusetts. As of now, there are 50 MinuteClinic locations with the majority of these locations on the eastern, more populated part of the state. Mapping the locations themselves provides insight to why CVS Health chooses certain stores to include a MinuteClinic. By mapping the median family incomes by county, it is evident that the majority of MinuteClinic locations are present in counties with higher median family incomes. It would seem that these areas with more wealth would have less demand for affordable retail clinics, however the goal of CVS Healths MinuteClinic is to work as part of a larger health care system.

2006 2007 2008 2009 2010 2011 2012

150

300

450

600

Year

Num

ber of Clinics



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$75,000 - $84,999

$65,000 - $74,999

$55,000 - $64,999

$45,000 - $54,999

Household Income

TARGET MARKETS

The market of users of retail medical clinics is evolving and becoming more widely used as services and locations expand to reach additional groups of the population. The section will look into the target markets of both retail medical clinics in general, as well as the target market that CVS Health is striving for.

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the clinic / target markets

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RETAIL CLINIC TARGET MARKETThe target market for the retail clinic can be looked at in a number of ways and compared across a wide scope of demographics. Some aspects to consider when deciding upon an ideal user are Age, Gender, Demographic, Education levels, Marital Status, Income, Residential Status, and locations of Residency. The charts are based on studies conducted by the Annals of Family Medicine (AFM)

According to the research, we can see that the majority of people who will seek medical assistance for minor illnesses and injuries in a retail clinic fit into this criteria: relatively wealthy, white women, with a bachelors degree, that are married, own a home, and live near a Metropolitan Statistical Area (MSA). While this is possibly the most common user, it is not to say that this is the only user or the ideal market. Retail clinics are trying to provide quality and affordable care to all of their patients.

Female

Male

Gender Ratio

Elderly

Adult

Adolescent

Age Groups


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WhiteBlackAsianHispanicMultiracial

Less than 12 High School/GEDCollege2-Year CollegeBachelors degreeProfessional degree

MarriedDivorcedSeparatedWidowsNever Married

Less than $25,000$25,000 - $49,999$50,000 - $74,999$75,000 or more

OwnRent

Lives in MSALives outside of MSA

Demographic

Education

Marital Status Place of Residence

Residential Status

Income

the clinic / target markets

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FUTURE TARGET MARKETAlthough the entire U.S. market purchases a growing amount of pharmaceuticals, CVS Healths target market is primarily focused on the elderly. Because of the explosion in the elderly population, CVS Health has a gigantic, growing market for its various services. Because they offer low cost, hands-on health care services, CVS Health is greatly benefiting from the demographic shifts and gains in the market share. Additionally, in store pharmacists help senior citizens navigate Medicare prescription plans, and with Medicare spending expected to rise 8.5% annually over the next decade. CVS Health has the most to gain by focusing on the elderly population growth. The bar graph represents the projected elderly population growth within the next forty years, showing that it will become even more important to target the elderly when marketing CVS Health and MinuteClinic. The pie chart shows the current percentage of the elderly population versus the adolescent and adult population. Although 18 percent may not seem like a large amount compared to adolescent and adult, people are living longer then ever before which means there will be an increasingly large amount of elderly, especially with the baby boomers who are starting to be labelled in the elderly range. These statistics show that it is increasingly important for CVS Health and MinuteClinic to consider the perspective of the elderly in their designs without ignoring the needs and perspective of both the adolescent and adult population as well.

2010 2020 2040 2050

50

75

100

125

Adult

54.8%

Elderly

18%

Adolescent

27.2%

Year

Num

ber of Elders (M

illions)


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SCOPE OF DIAGNOSTICS

CVS Health MinuteClinics offer a range of services to be provided by either a nurse practitioner or a physician assistant. All of there services mimic that of a primary care physician, however the care can be received without a prior appointment when the care is needed. All MinuteClinic locations have all necessary equipment to diagnose and treat most common ailments.

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the clinic / scope of diagnostics

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MEDICAL PROFESSIONALSRetail Medical Clinics specialize in primary health care provided by either a nurse practitioner (NP) or a physician assistant (PA). They provide many of the same services received from a doctor, including prescribing medicine, treating common illnesses, administering vaccinations and physical examinations without needing an appointment through a primary care doctor. With this rise in retail clinics, 1 in 6 people with better or average health use a retail clinic over their primary physician.

Most clinics are staffed with a nurse practitioner, which is a registered nurse who has acquired the knowledge base, decision-making skills, and clinical competencies for expanded practice beyond that of a registered nurse (RN). A survey taken in 2012 of Nurse Practitioners showed nearly 57 percent of nurse practitioners worked under a private physician and 2.2 percent reported as working in retail clinics opposed to other positions. Some states require a physician assistant within their retail clinics, a physician assistant is a health care professional licensed to work under the umbrella of a registered physician and provide the same services as a nurse practitioner.


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Number of Jobs:

Unemployment Rate:

USNews Best Jobs of 2014:

Education:

Certifications:

Physician Assistant (PA)33,30038.4% Growth Rate

1.2%

#13

Bachelors Degree (2-4 years science coursework)Masters Degree (2-3 Years)2,000 Hours Clinical Rotations

National Commission on Certification of Physician assistants

37,10033.7% Growth Rate

0.9%

#4

Bachelors Degree in NursingGraduate Degree

National Council Licenser Examination for Registered NursesAdvanced Practice Registered Nurse (APRN)

Number of Jobs:

Unemployment Rate:

USNews Best Jobs of 2014:

Education:

Certifications:

Nurse Practitioner (NP)

the clinic / scope of diagnostics

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Minor Illness Exams:

Allergysymptoms

Bronchitis/cough

Earache

Earinfection

Flu-likeSymptoms

Mono

MotionSickness

Preventions

Pinkeyes

Styes

SinusInfection

SoreThroat/Strep

Upperrespiratoryinfection

Urinarytract

Bladderinfection

Minor Injury Exams:

Blisters

Bugbites+stings

Jellyfishstings

Lacerations

Minorburns

Minorwounds+abrasions

Splinterremoval

Sprains/strainstoankles+

knees

Suture/stapleremoval

Tickbites

Skin Condition Exams:

Acne

Athletesfoot

Chickenpox

Cold+cankersores

Impetigo

Lice

Minorinfections

Minorrashes

Oral/mouthsores

Poisonivy+oak

Ringworm

Scabies

Shingles

Sunburn

Swimmersitch

Wartevaluation

Get

Hea

lthy

CLINIC SERVICES


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Wellness + Physical

Exams:

Screens(basic

health,cholesterol,

comprehensivehealth,

diabetes)

Physicalexams

(administrative,camp,

college,sports

Earwaxremoval

EpiPen+Twinjectrefills

Medicationrenewal

Pregnancyevaluation

StarttoStopsmoking

cessation

TBtesting

Weightlossprogram

Health Condition Monitoring: A1ccheck Diabetes Highbloodpressure Highcholesterol

Vaccinations:

DTaP(diphtheria,

tetanus,pertussis)

Flu

HepatitisA

HepatitisB

HPVGardasil

Meningitis

MMR(measles,mumps,

rubella)

Pneumonia

Polio

Td(tetanus,diphtheria

Tdap(tetanus,

diphtheria,pertussis)

Sta

y H

ealth

y

Pot

entia

l Add

ition

al S

ervi

ces

Opportunities for

future services:

Performsimple

procedures

(biopsies,sutures)

Sprains,strains+

fractures

Lacerations

Painmedication

(migraineor

otherwise)

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HOW + WHERECARE HAPPENS

exam room functionalitytelemedicine

infusion therapy

346070

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EXAM ROOM FUNCTIONALITY

This research aims to develop a better understanding of a typical exam room in a CVS Health MinuteClinic. The research has culminated in an understanding of the existing equipment, storage, and supplies in an exam room, and the spatial arrangement relative to these. This research also proposes methods for how the CVS Health MinuteClinic can be more efficient with space to enhance storage and productivity, while also, prospectively expanding upon its care-giving services.

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Two 2 x 4 ceiling lights

Germ Guardian

ADA Accessible Sink

Task ChairGuest ChairExam Bed

how + where care happens / exam room functionality

EXAM ROOM EXISTING CONDITIONS

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1. Exam Table2. Blood Pressure Monitor3. Otoscope4. Storage

1. Computer2. Storage3. Brochures/Pamphlets4. Phone5. Office Supplies

1. Sink2. Refrigerator3. Bio-waste/Sharps collection4. Basic First Aid/Exam Resources5. Hand Sanitizer


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Refrigerator

Hazard Box / Blade Storage

Sink + Emergency Eye Wash Station

Patient Chair

Computer


Telephone

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Stethoscope

Otoscope

Blood Pressure Monitor

Exam Bed

Height Chart

Eye Exam Chart


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Exam Room StorageThis study shows the components that make up all the equipment and storage in a typical CVS Health MinuteClinic exam room.

x 3

x 5

x 4

x 4

x 1

x 1

Upper Storage Space Base + Lower Storage Space


2 6

2 6 1

1

3

1

2 11

2 3

1 2

6

1 8 1 8

6

1 5 1 7

2 6

2

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x 1

x 1

Flat Surface Storage Space


6 62

4 62

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Treatment

Grouped by importance of proximity

Exam Room Component SpectrumThis diagramming study arranges the equipment and furniture of an exam room along a spectrum relative to their function, and importance of proximity to one another.


Treatment & Storage

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Storage

45 sqft (cubic square foot) of overhead and base cabinets


Treatment & Storage

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Current Exam Room

The volume is 10 ft. x 10 ft., with an approximate 8 ft. ceiling height. All of the walls are covered with various cabinets or exam equipment.

Current Exam Room - Exam Table + Wasted Space

The removal of the bulky table would remove services, but lend more space to the store.

Exam Room

Subtracted Equipment

Wasted Space

Additional Equipment


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Current Exam Room - Provider Work Station

Some nurse practitioners enjoy the desk while others believe it takes up too much room and can be replaced with a more flexible and portable station.

Current Exam Room + Additional Equipment

The additional equipment may include an EKG machine, an x-Ray machine, additional mini fridge, and additional patient chairs.


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This diagramming study progressively updates the exam room furniture and equipment, based on feedback from research and interviews with Nurse Practitioners. To show the maximum impact the exam room has been updated within the existing 10 x 10 constraints of the typical exam room.

EXAM ROOM MODIFICATION STUDIES

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Extend or increase

storage to store more supplies and potentially expand upon

services.

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Replace typical built desk with rolling stool and mobile work station to increase floor space, and NPs connection to patients.

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EKG Machine Addition

to increase service scope.

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Existing Exam Room Spatial Analysis


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Modified Exam Room Spatial Analysis


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Inclusive Design The following clinic layout design manipulates the current fit out clinic dimensions of two 10 x 10 clinic rooms, so a total area of 200sqft. This design in based on research collected by peer-reviewed sources and interviews with users, and nurse practitioners. This design includes an accessible lift designed by Prism Medical to aid handicapped patients; allowing them to receive medical check ups on the exam table including physicals by the nurse practitioners, which previously could not have been done.

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12 8


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8

10

12

8

54


55


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In the existing set up the Nurse Practitioner has a long distance to move and can only get to these places by standing up and walking to these spots. Currently, the chair is also quite big and bulky, not allowing agile mobility.

The new proposal allows the Nurse Practitioner to move around the room fairly quickly while still being seated on the stool. It also enables the nurse practitioner to treat a patient while they are in a stool even if the patient is on the exam bed.


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The new proposal allows the Nurse Practitioner to move around the room fairly quickly while still being seated on the stool. It also enables the nurse practitioner to treat a patient while they are in a stool even if the patient is on the exam bed. Furthermore, it allows a physically disabled patients to receive medical examinations with the assistance of a lift, that could also lift the patient to the sink.


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Jain Malkin The design of healing environments quickly became an industry buzzword after publication of Jain Malkins book Hospital Interior Architecture in 1992 which promoted the concept of research-based design. Jain has guided thousands to the ideas of designing the patient experience

Case Study: Scripps Center for Integrative Medicine:

A Healthcare design based on a sacred geometry becomes a physical expression of the mind-body-spirit harmony that is the goal of integrative medicine. Golden ratio represents a mathematical relationship known to create feelings of harmony and comfort.


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Sight-lines Alan Rheault in his research states, information on a computer or handheld device are limited to only the physician, which compromises the powerful potential of technology as a tool for teaching and learning. Teaching and learning goes both ways patients and family sharing with physicians, physicians sharing with patients and family, and the configuration of space is fundamental for supporting that. In many exam rooms today, fixed, bulky furniture makes movement difficult, limits in-the-moment reconfiguration, and hinders active learning modes. Making technology and tools mobile can support a more dynamic flow.


TELEMEDICINE

Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patients clinical health status. Telemedicine includes a growing variety of applications and services using two-way video, e-mail, smart phones, wireless tools and other forms of telecommunications technology.

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how + where care happens / telemedicine

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1955

2015

2000

1985

1970

In the early 1960s, NASA

measured physiologi-cal mea-

surements of astro-

nauts during space flights

STARPAHC was devel-oped by NASA to deliver

health care to the isolated Papago Reservation in

Arizona. Portable diagnos-tic equipment was linked to a two-way microwave

transmission

NASA study to de-termine the minimal

television system requirements for

accurate telediag-nosis

The develop-ment and wide-spread access of the internet encouraged a

boom in the use of telemedicine

First international telemedicine project,

offering medical consul-tations from doctors in the U.S. after an earth-

quake in the Soviet Republic of Armenia.

Over 130 telemedicine research sites, the

majority of which use two-way interactive

audio-visual technology

American Telemedicine Association was estab-

lished to provide guide-lines and best practices for telemedicine

200 telemedicine networks, over

3,500 service sites, hosting 500,000

interactions in 2012 by top three

networks alone

Over 1 mil-lion Americans wearing remote cardiac monitors

GROWTH AND USE

Telemedicine can be used in different forms to provide care in a variety of ways. Each use requires the use of equipment to exchange information, although the complexity of the tasks vary. The fol-lowing are ways that telemedicine is currently being practiced in the United States:

Monitoring-remote patient monitoring uses de-vices to remotely collect and send data to a home health agency or a remote diagnostic testing facility for interpretation. Such applications might include a specific vital sign or a variety of indicators for home bound patients. This can serve both as early warn-ing systems and treatment compliance monitoring.

Diagnosis-this may involve the use of live interac-tive video or the use of store and forward transmis-sion of diagnostic images, vital signs and/or video clips along with patient data for later review.

Virtual Visits/Consultations-primary care and specialist referral services may involve a primary care or allied health professional providing a con-sultation with a patient or a specialist assisting the primary care physician in rendering a diagnosis.

Triage-offering the ability to remotely sort pa-tients according to urgency

Procedures-procedures that can be undertaken remotely


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Law AdoptedProposed LawPartial Law

Telemedicine Parity Law requires private insurance to cover telemedicine the same as an in-person service.

Technical C

omplexity

Potential Benefits of Use

Triage

Procedures

Diagnosis

Virtual Visit/Consultation

Monitoring

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According to the Association of American Medi-cal Colleges, by 2020 the U.S. is projected to have 91,500 fewer doctors than needed. Telemedicine has the potential to provide services to relieve the strain of a care provider shortage by provid-ing increased access. Not only does telemedicine improve access to patients, but it allows physicians and health facilities to expand their reach beyond their own offices.

Patients also have the potential to benefit from vir-tual care. Telemedicine technology has the poten-tial to reduce travel time and other stresses for the patient, when having to physically go to get care. Such services can offer patients access to provid-ers that might not be available otherwise to them.

Telemedicine can be a cost efficient, both for the patient and the health care system. The average cost of a virtual e-visit costs $35-$50 dollars, in comparison to $133 on average for an in-person visit at a primary care physicians office. Reducing the cost of health care is one of the most important reasons for funding and adopting telehealth tech-nologies. Telemedicine has been shown to reduce the cost of health care and increase efficiency through better management of chronic diseases, shared staffing, reduced travel times, and fewer or shorter hospital stays.


Equipment for telemedicine practice depends on the extent of communication. Common equipment for remote diagnosis, consultations, and treatment include the following:-Store & forward technology for obtaining and transmitting data to a remote site through the use of a computer with a secure system-A high-speed internet connection if videoconfer-encing is involved-Telemedicine practitioners cart, including a moni-tor, computer, and camera-Additional instruments include a digital stetho-scope, otoscope, ophthalmoscope, and total exam camera

BENEFITS AND POTENTIAL


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Reasons for E-Health Visits

Respiratory Illness

UTI/B

ladder Infection

Abdominal Pain

Procedure Follow Up

Joint/Back Pain

Viral Illness

General Advice/Refills

Eye Problem

Ear Infection

Other

Immunizations

Screening Lab Test

Other

Reasons for Retail Clinic Visits

69.5% 30.5%

Retail clinic services that could be offered through telemedicine

Physicals?

Minor Injuries

Skin Conditions

Wellness

???

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Option 1Treat most patients remotely from their homes, but still have capability to provide immunizations and health screenings in the location of the nurse practitioners office.

-0 exam rooms-1 nurse practitioners office-1 nurse practitioner on site

Pros-does not require a full exam room but most of the services currently offered could still be provided.

Cons-must refer patients to a physicians office if they cannot treat them remotely because they are not equipped to treat them in the retail location. Cannot provide physicals or other procedures that require an exam table.

5

SPATIAL IMPACT OF TELEMEDICINE IN A RETAIL CLINIC


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Option 2Treat patients remotely first, but keep an exam room to treat patients that you cannot be remotely treated and to provide patients with immunizations, screening tests, physicals etc.

-1 exam room-1 nurse practitioner on site

Pros-can provide all services that are currently be-ing offered at retail clinics using less physical space for the clinic.

Cons-Limited number of patients could be treated with one care provider attending to both physical patients and remote ones

5

68


Option 3Keep an exam room to treat patients that cannot be treated remotely and to provide immunizations, screening tests, physicals etc. Also provide a virtual portal to treat overflow patients with a nurse practitioner at a remote retail location.

-1 exam room-1 virtual portals-1 nurse practitioner on site

Pros-when there is a surplus of patients, the patient can remotely contact a nurse practitioner at a sister location. In this way, the locations of the clinics reach more areas, with a staff that can be shared between them for efficiency. The portal also allows patients to have access to digital diagnostic equipment that they may not have at home.

Cons-more space is used than in other options. If there is not a surplus of patients, the nurse practi-tioner and the portal are not both needed and one of the rooms will not be occupied.

5

5


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Option 4Provide only patient portal(s) at certain locations with necessary equipment for a remote diagnosis from a nurse practitioner at another retail location, which may or may not include a full exam room.

-1 or 2 virtual portals-0 nurse practitioners on site

Pros-allows fewer clinics to reach more areas and patients with fewer care providers. The portal also allows patients to have access to digital diagnostic equipment that they may not have at home.

Cons-must refer patients to a physicians office if they cannot be treated remotely, as there are no care providers on site. Cannot provide physicals or other procedures that must be given in person. Immunizations may take place at pharmacy (as in many current retail locations).

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5

INFUSION THERAPY

Typically infusion therapy is medication adminis-tered intravenously through a needle or catheter, but can also be provided through intramuscular injections and epidural routes. These medications are often prescribed when a patients condition is so severe that it cannot be treated effectively by oral medications.

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how + where care happens / infusion therapy

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USE AND BENEFITSInfusion therapy can be provided via a hospital-based infusion clinic, a physician-based infusion clinic, or an ambulatory infusion suite (AIS) of a home infusion therapy provider. These are most commonly staffed with RNs and registered phar-macists who have had special training in infusion and specialty drug administration. Obtaining the therapy through a service at a patients home or at an infusion suite results in a much lower cost, as the patient is not staying at a hospital, and allows the patient to be discharged and return to their lifestyles at their homes.

Infusion times range from 30 minutes to 6 hours depending on the physicians prescription and the rate at which an individual absorbs the medication. Some patients may need infusion therapy daily, while others may only get it periodically or when prompted by symptoms.

After hour and weekend appointments are some-times offered to provide a flexible care schedule.

medication

TYPICAL: antibiotics antifungal antiviral chemotherapy hydration pain management parenteral nutrition

SPECIALTY: blood factors erythropoietin inotropic heart medi-

cations growth hormones immunoglobulin natalizumab corticosteroids infliximab

illness

infections that are unresponsive to oral antibiotics

immune deficiencies cancer dehydration chronic pain gastrointestinal dis-

eases

hemophilia anemia congestive heart

failure hormone deficiencies autoimmune disease multiple sclerosis rheumatoid arthritis


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1-3 Coram ambulatory infusion suitesno Coram ambulatory infusion suites

4+ Coram ambulatory infusion suites

12:00 1:00 2:00 3:00 4:00 5:00 6:00

average length of infusion session

Duration of Therapy Session

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SERVICESInfusion therapy clinics are responsible for ensuring that the infusion drugs are: compounded in a sterile environment maintained in appropriate conditions to ensure sterility and stability

administered at exactly the right dose and on the right schedule

administered using the appropriate vascular access device (often a long-term device), which is placed in the correct anatomical location based on the expected duration of therapy, the pH, osmolarity, and osmolality of the medication (Picc lines, Q Ports)

administered using an appropriate drug delivery device

flushed with the proper flushing solution be-tween doses

monitored for adverse reactions and therapeu-tic efficacy

Clinics require infusion pumps and poles, IV sets, and syringes

Amen

ities for Patients

wireless internet

television

food + drinks

blankets


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comfortable chair

table ability to recline

foot rest

IV pole andinfusion pump

guest seat(s)

76


THERAPY SPACEnon-private

Goldschmidt Infusion Center, Jefferson City MO

10-6

7-0


semi-private

Seidman Cancer Center, Cleveland OH

77

7-6

8-6

78


semi-private

El Camino Cancer Center, Mountain View CA

7-69-6


79

private

Brooklyn Infusion Center, New York, NY

9-6

8-0

81

WAITING + PRIVACY

psychology + management tacticsprecedents

variable to consideridentifying patterns

8294108136

81

82

PSYCHOLOGY + MANAGEMENT TACTICS

Waiting rooms set the tone for the medical experience. Patients' perception of how long they have waited can greatly affect their satisfaction of the overall visit. Therefore, it is important to provide for choice within the design. Patients will likely have some level of anxiety, and, according to their psychological make-up, they will have a varied response regarding a need for personal space and privacy.

waiting + privacy / psychology of wait

84

PSYCHOLOGY OF WAITWaiting is frustrating, demoralizing, agonizing, aggravating, annoying, time consuming and incredibly expensive.According to David Maister in The Psychology of Waiting Lines, the truth of this assertion cannot be denied: there can be few consumers of services in a modern society who have not felt, at one time or another Products are consumed, services are experienced. Accordingly, if managers are to concern themselves with how long their customers or clients wait in line for service (as, indeed, they should), then they must pay attention not only to the readily-measurable, objective, reality of waiting times, but also how those waits are experienced.

If they sit down in a good mood, its easy to keep them happy. If they sit down disgruntled, its almost impossible to turn them around. Theyre looking to find fault, to criticize.

First law, Satisfaction= Perception -Expectation The point, of course, is that both the perception and the expectation are psychological phenomena. They are not the reality. In a benevolent world, both the perception and the expectation will have some connection to reality, but they are not reality.If you expect a certain level of service, and perceive the service reviewed to be higher, you are a satisfied client. If you perceive the same level as before, but expected higher, you are disappointed and, consequently, a dissatisfied client.

Second law is that its hard to play catch-up ball. The corollary to this law is the proposition that there is a halo-effect created by the early stages of any service encounter, and that if money, time and attention is to be spent in improving the perceived quality of service, then the largest payback may well occur in these early stages.

TIME ATTENTIONCOST PROFIT


85

Perceptions - Expectation = Satisfaction

CUSTO

MER SAT

ISFA

CTION

= -EXPECTATION

PERCEPTION

Dissatisf ed S

atisf ed D

elighted

Expectation

Perception

Expectation

Perception

Expectation

Perception

MANAGING TACTICS

waiting + privacy /managing tactics

86

People Want to Get Started.According to David Maister in The Psychology of Waiting Lines, this is why restaurants give you a menu while you wait, and why doctors put you in the examination room twenty-five minutes before your examination actually begins. One of the other virtues of handing out menus, providing a drinks bar and other methods of service-related time-fillers is that they convey the sense the service has started: we know that you are here. Many restaurant owners instruct their service staff to pass by the table as soon as the customers are seated to say Ill be with you as soon as I can, after Ive looked after that table over there. In essence, the signal is being sent: We have acknowledged your presence.

Anxiety Makes Waits Seem LongerIf you think youve chosen the slowest line, or youre worried about getting a seat on the plane, the wait will seem longer. Maister noted a large part of the concern that we feel to get started is due to anxiety. The anxiety was about whether or not one had been forgotten. Anxiety can come from other sources. Nearly everyone has had the experience of choosing a line at the supermarket or airport, and stood there worrying that he had chosen the wrong line. As one stands there trying to decide whether to move, the anxiety level increases and the wait becomes intolerable. This situation is covered by what is known as Erma Bombecks Law: The other line always moves faster.


87

Occupied Time Feels Shorter Than Unoccupied Time.As William James, the noted philosopher observed: Boredom results from being attentive to the passage of time itself. When you have something to distract yourself, time passes more quickly. Some hotels put mirrors by the elevators, because people like to look at themselves. Maister declared that the truth of this proposition has been discovered by many service organizations. In various restaurants, it is common practice to hand out menus for customers to peruse while waiting in line. This suggests that the activity provided to fill time should (a) offer benefit in and of itself, and (b) be related, in some way, to the following service encounter.

Solo Waits Feel Longer than Group WaitsThe more people engage with each other, the less they notice the wait time. In fact, in some situations, waiting in line is part of the experience. Maister noted in his article that one of the remarkable things to observe in waiting lines is to see individuals sitting or standing next to each other without talking or otherwise interacting until an announcement of a delay is made. Then the individuals suddenly turn to each other to express their exasperation, wonder collectively what is happening, and console each other. What this illustrates is that there is some form of comfort in group waiting rather than waiting alone.


88

Uncertain Waits Are Longer than Known Finite WaitsPeople wait more calmly when theyre told, The doctor will see you in thirty minutes than when theyre told, The doctor will see you soon. Maister gives an amusing illustration of a phenomenon that anyone might experience: if you arrive some-place thirty minutes early, you will wait with perfect patience, but three minutes after your appointment time passes, you start to feel annoyed. Just how long am I going to have to wait? You would think. Similarly, the pilot who announces only a few more minutes adds insult to injury when the wait goes on and on. Not only are the customers being forced to wait, but they are not being dealt with honestly.

Unfair Waits Are Longer thanEquitable WaitsPeople want their waits to be fair. You get anxious, for instance, when you are waiting on a crowded subway platform, when theres no clear, fair way to determine who gets on the next car. The FIFO rule (first in, first out) is a great rule, when it works. But sometimes certain people need attention more urgently, or certain people are more valuable customers. Then it gets trickier. Often, when people are treated out of sequence, its helpful to have them be served elsewhere, for example people giving customer service by phone shouldnt be in the same room as people giving service in person. As Sasser, Olsen, and Wycoff note, one of the most frequent irritants mentioned by customers at restaurants is the prior seating of those who have arrived later. They observe: The feeling that somebody has successfully cut in front of you causes even the most patient customer to become furious. Great care to be equitable is vital. Instead of being able to relax, each individual remains in a state of nervousness about whether their priority in the line is being preserved. As already noted, agitated waits seem longer than relaxed waits. It is for this reason that many service facilities have a system of taking a number, whereby each customer is issued a number and served in strict numerical order.


89

Unexplained Waits Are Longer thanExplained WaitsWe wait more patiently for the pizza guy when theres a thunderstorm than when the sky is clear. We wait more patiently on the plane when we know that theres another plane at the gate. Maister illustrates if a doctors receptionist informs you that an emergency has taken place, you would wait with greater equanimity that if you do not know what is going on. Airline pilots understand this principle well; on-board announcements are filled with references to tardy baggage handlers, fog over landing strips, safety checks, and air traffic controllers clearance instructions. Naturally, justifiable explanations will tend to soothe the waiting customer more than unjustifiable explanations.

The More Valuable the Service, theLonger the Customer Will WaitYoull wait longer to talk to a doctor than to talk to a sales clerk. Youll stand in line longer to buy an iPad than to buy a toothbrush. Maister points out that the example of the supermarket express-checkout counter reminds us that our tolerance for waiting depends upon the perceived value of that for which we wait. Special checkout counters were originally provided because customers with only a few items felt resentful at having to wait a long time for what was seen as a simple transaction. Customers with a full cart of groceries were much more inclined to tolerate lines.


90

InlineAccording to Jenny Fillippetti on design boom Inline is designed as a dynamic, smart phone equivalent to the information presented by folio. Ones current number in queue is updated in real-time, users can take notes and access medication records, and health tips can be stud-ied through applications with an intuitive interface.

Features

Suggestions are offered for healthy activities in your area. Make healthcare appointments online. Get directions to the consultation room. Patient queue is updated in real-time. Keep notes and medication records to prepare for con-sultation.

Plan your wait with a text update!Nobody likes spending hours and hours sitting around a crowded waiting room, not knowing who will be called next. So imagine if patients and families could be notified via text message about the number of patients ahead of them while grabbing a bite to eat or going for a walk?

According to McGill University Health Centre, Patients and families visiting the Montreal Childrens Hospitals Emergency Department (ED) can sign up via their smart phones or by registering at a kiosk located just outside the EDs triage area. The service lets them wait in a virtual waiting room rather than a physical one with the help of their cell phonessomething thats sure to please more than a few stressed-out parents.


91

Main Menu Navigation Wait Queue Take Notes Medication Support Health Activities

Choose A Doctor Based On Whose Available When You

Need Them

Receive Text Alerts When Time Slot

Nears

Schedule Appointment

Wait Travel Enter Self Check-In Kiosk

Shop While Waiting

Exam RoomSee Medical Staff

Exit

waiting + privacy /managing tactics synthesis

92

Tactics Shortens wait time Tactics Affect on Perception

Tactics Association Apps

Fairness

Anxiety

Certainty

Occupied

Starting

Group

Explain

AppsOccupied

Certainty

Group Fairness

Ex-

Anxiety

Apps

Certainty

Occupied

Starting

Explain

Group

Anxiety

Fairn

ess

Value

Tactics manages expectations

Tactics manages perception


93

76% 50%

Good Experince Bad Experince

Customer satisfaction is improved by 76% if they perceived that the wait time they expected, became shorter. By applying the tactics mentioned, better experi-ences will be felt.

Customer dissatisfaction is more likely to be experi-enced by 50 %, if non of the psychological tactics were applied.

Psychological tactics and Customer Satisfaction

PRECEDENTS

Looking both at typical examples of precedents as well as new innovative waiting experiences, one can understand a broad view about the factors that determine a patient's comfort and privacy while waiting. Taking into consideration factors such as density of occupancy, dedicated space for waiting, and adjacencies to a waiting area, a broader understanding of waiting and privacy can be obtained.

94

96

waiting + privacy / precedents

CONVENTIONAL PRECEDENTS

Density of occupancy

Dedicated space for waiting

Bus StopsStops typically provide shelter, seating, bus schedules, and route information. Standing and sitting areas are usually both provided. Advertisements are often incorporated into the walls of the shelter.

Waiting Area

Bus

97




Shoe Shine StandsShoe shine stands unlike shoe shine boxes, which are more portable, are often in established locations. They are typically elevated and provide storage below. The stand is often set against a wall or has a back to provide comfort for the customer. The waiting and servicing experience doesn't require the customer to move. The customers are often passerbys. The entire process can take from 15 to 20 minutes for both shoes. The customer can read a paper or magazine while waiting.

Waiting Area

98




Recept.

WC

Entry

Staff Works

AutoshopsBack to back sociofugal seating arrangements are typically seen in autoshops. Customer seating is often in close proximity to the reception area. The staff working at the counter can usually see the waiting area from behind the desk. Reading material is often provided.

Waiting Area

99




Security

WC

Entry

Shop Dining

CheckIn

AirportsRows and rows of side by side seating are frequently seen in airport terminals. Efficiency is usually considered before comfort. Armrest spacing varies to accommodate people of different sizes. Seating is typically adjacent to the tarmac so that those waiting don't have to go far once the plane is ready for loading.

Waiting Area

100


INNOVATIVE PRECEDENTS



Entry

Bus

Bus StopPassengers at stops are alerted to bus wait time. The platform height matches that of bus access. Fares are prepaid, and buses travel in their own lanes. This has resulted in reduced travel time.

Curitiba Bus Rapid Transit System

Waiting Area

101




Recept.

WC

Entry

Exam Offices

Dental OfficeThe clinic has been designed as a complete space rather than as separate areas. There is a resulting linear flow from the moment of arrival until completion of the dental services.

Estudio Arquitectura Hago

Waiting Area

102




Retail

Entry

Waiting Area

RetailSeating in this underground store is centrally located. Seating is intended for family and friends of shoppers. Seating is arranged adjacent to the main architectural element. Customer payment utilizes a handheld EasyPay system.

Apple Store - Fifth Avenue

103




Board

WC

AirplaneThese innovative airline seats offer control, comfort, and flexibility. A dividing screen is provided in the middle aisle to create isolation from the other passengers as well as a sliding door along the aisles. When the dividing screen is down, a shared center table is activated allowing shared interactions between two people.

Waiting Area

Etihad

104




WalgreensTwo distinct waiting areas are realized here in the Walgreens model. For brief questions a customer can obtain help at the information desk. If the information demands are greater, seating is provided near an additional customer service area.

Retail

Pharm.

Entry

Waiting Area

WC Clinic

105


106


PRECEDENTS SYNTHESIS ANALYSISOrganization of the chart is based on two variables: dedicated space to waiting and density of occupancy. The third variable is the spatial sequence of each precedent which is represented by the size of the circles. The shortest sequence with the highest dedicated space for waiting and density of occupancy is the shoe shine stand because the services and waiting space are unified as one component. A typical airport and airplane waiting experience usually revolves around waiting as is needed for the service provided. The Walgreens store offers two different options for the customer which can either decrease or increase the spatial sequence. The typical autoshop and dental office experience are similar in their offerings for waiting. The Curitiba Bus Rapid Transit System does not require as much seating because its efficiency allows patrons to be serviced faster due to its rapid turnover. The Apple Store's innovative new shops work to keep the potential customers occupied or have a dedicated salesman ready to answer any questions. The business model is to not keep any customers waiting.

Spatial Sequence Low To High



Retail

Pharm.

Entry

Waiting Area

WC Clinic

107


Airport

Walgreens

Airplane

Autoshop

Dental

Bus Stop Inn.

Apple Store

Shoe Shine

Density of Occupancy

Ded

icated

Spa

ce for W

aitin

g

Bus Stop Typ.

VARIABLES TO CONSIDER

A combination of variables set the tone for the waiting experience and a sense of privacy. Variables include seating arrangements and types, the level of exposure or isolation, the level of control and types of lighting, exposure to noise, and visual stimulation as well as positive distractions.

108

110

waiting + privacy / variables to consider

SEATING ARRANGEMENTS

Sociofugal ArrangementSociofugal spaces discourage interaction and create privacy within crowded settings. They place patients outside of personal intimate zones. For settings that do not provide enclosed spaces to retreat, sociofugal seating can create a sense of solitude in crowded settings.

Sociopetal ArrangementSociopetal spaces encourage interaction and communication between people. Clustered seating arrangements tend to create sociopetal spaces. Individuals and groups of all sizes should be considered as patients congregate in different sizes.

Shorecare Accident & Medical

111


CombinationA combination of seating arrangements accommodates a variety of groups' sizes and allows patients to choose whether they congregate or separate themselves from others. Instead of lining chairs up in rows along a wall, people can separate themselves from others, mingle, relax, connect, or absorb information. With a few adjustments, a patient can be offered features that make better use of their time and create positive distractions. The furniture offers easy access to power outlets and several other integrated features. The Regard furniture line by Steelcase allows patients to access medical

information while waiting, creates privacy, and offers these technology supports.

Steelcase Health

112


GridA rigid placement of seating in alignment to adjacent programs can offer an efficient use of square footage while still allowing for a combination of seating arrangements. The configuration of furniture usually follows the patterns created by the architectural elements.

OrganicAn organic configuration with curved walls, floor thresholds, or furniture arrangement can contribute to a relaxed environment while offering a combination of options for different seating comforts based on the patients' varied response regarding a need for either personal space or sociability.

The Mother Baby Center Pediatric Clinic

113


Frankfurt Airport

114

waiting + privacy / identifying patterns

Flexibility of Seating in Limited SpaceFolding tables help to save seating space. Seating could be rotated 180 to guarantee that it is facing in the direction of travel. Group travelers can sit face to face to enjoy more intimacy. This could enable healthcare institutions with limited waiting space.

Typical Unfolded Folded

TGV High Speed Train, China

115


Air New Zealand's Spaceseat

116


MODULAR SEATING

Integrated SeatingOften a patient's time is wasted doing nothing because waiting rooms only provide places to sit. The waiting space can integrate more opportunities to work, snack, watch TV, or provide charging stations for personal electronics. Patients would then be given several opportunities to spend their time more valuably to promote waiting productively. The modular seating arrangements can create both private and communal seating configurations. The colors and walls integrated into the design also create a way-finding element. The flexibility in the design takes into consideration seating for people of various sizes and physical abilities.

The modular furnishing also makes it possible to reconfigure the components for future needs. Seating arrangements can also provide a comfortable setting for families and clinicians to meet. Wall panels adjacent to seating areas reduce noise and other distracting stimulations.

Steelcase Health

117


A privacy screen can be added which creates a greater sense of seclusion.

Touchdown spaces are provided which could be utilized for check-in, to look up health tips, or use laptops for work.

Arm rests can be relocated for extra-wide seating to accommodate people of different sizes.

Cubbies create space for magazine racks, a place for backpacks, or shelving to keep personal belongings off floors.

Frame extensions create great flexibility for re-configuration to allow for future needs and offer easy replacement of parts.

Power outlets, armrests, and surfaces for holding beverages are combined in modular units that can be located where needed.

118


LoveseatsOffer an intimate seating arrangement for family and friends. Can be arranged for a social setting.

Freestanding Chair & TableA freestanding chair and table allows flexibility for seating to be arranged for individuals to sit by themselves or for groups to add additional seating to a fixed arrangement. An additional table can create a comfortable social distance and function for several needs.

Multi-Functional SeatingRegard's modular seating can be combined to serve purposes for several different occupants' needs. An end seat allows sole individuals to sit comfortably by themselves, while the couches provide an intimate seating arrangement for those looking to interact with others. The other end offers a work space that can be used for signing in or working. An end panel creates separation and can be used alternately as a wayfinding element.

Bench SeatAllows for several occupants to sit comfortably for an extended period of time. The shared table can be used for work, meals, or play. The side of the table can be used for an additional seat if needed.

CouchA planted back provides a freestanding seat with some privacy, and adjustable armrests can be rearranged to suit people of different sizes.

OttomansA cushion provides comfort while the small size allows for easy rearrangement. Allows for patients to sit in any direction which is comfortable for the occupant.

119


Steelcase Health

120


WAITING ROOM BOUNDARIES

Completely OpenOften reception desks are oriented to face seating and circulation in order for the patients to be able to see where they are in line. The reception area becomes a major focal point in this arrangement which can provide a sense of security for the patient. They can be reassured they have not been forgotten if they can be seen and are able to see the staff. Setting the reception desk a few feet away from the seating area and creating thresholds in the floor will assist, and separating the queuing line does not interfere with circulation or the waiting area. Setting the start of the queuing line at least four

feet from the reception desk will help ensure a patient's auditory privacy. Providing too many seats wastes space, while too few is worse because of the perception of crowding, lack of available choices, and forcing patients to stand or move. This could cause additional stress or discomfort for patients. It is important to find a balance between the need for peak demands and conserving space. Seating should accommodate a wide range of users, groups' sizes, social interactions, and distractions for passing time. A flexible grouping to allow for an additional chair should be considered.

American-Sino Hospital American-Sino Hospital

121


Primary Circulation

Reception

Lower Cei

ling

Structural Grid

PCC Austin Family Health Center

122


Separation at SeatingIf patients wish, they should be able to avoid the gazes of others. Therefore, not all seating should be oriented face to face. People typically prefer having their backs against a wall or divider. Typical side by side arrangements inhibit social interaction which may be desirable. Seats with armrests provide some sense of separation from the neighboring seats. A patient's needs for privacy varies for each individual. A patient might seek solitude for contemplation or a personal connection with family, friends, or with the medical staff. They also may need to be able to protect their personal information about

themselves from strangers. It is in violation of HIPAA guidelines and a threat to a patient's privacy to discuss a patient's condition within earshot of others. Therefore, it is critical to provide some separation between the exam room and the waiting area. Two significant factors in reducing unwanted sound are adjacency and materials. Providing walls around a seating area with sound absorbing materials can reduce unwanted noise as well as increase speech intelligibility. At the same time, this would serve to reduce any potential violations of speech privacy.

Tenteki 10 Omotesando L2ds Women's Medical Clinic and MRI Center

123


Prim

ary

Circ

ulat

ion

Lower Ceiling

Implied Bou

ndary

Adjac

ent E

ntry

Obata Clinic

124


Walls & CurtainsPrivate areas should be differentiated from more public areas through the use of implied or real thresholds and features such as lowered ceilings, changes in floor level, floor/wall/ceiling materials, and variations in lighting. This could be accomplished by utilizing a half wall, opaque glass, columns, level changes that are ADA compliant, or alcoves. Locating bathrooms or other rooms between waiting and exam rooms will give isolation from corridors or larger function areas. A waiting area that is entirely open to the space around it, that is just distinguished by the floor, ceiling, or seating

arrangement, is typically not comfortable for patients who are completely exposed. Finding a balance between a completely exposed area and a completely enclosed room is ideal. By creating a semi-private space, patients can observe everything around them while still maintaining privacy. To accommodate varying degrees of visual and acoustic privacy that can be adjusted, provide elements such as movable screens, dividers, and curtains. Provide furniture that can be rearranged and a space that can accommodate different arrangements. Provide lighting, television, and control of music.

Grace Hill Neighborhood Health Center

125


Primary

Implied

Thres

hold

Sepa

rate L

ightin

g

Secondary

Regent Insurance

126


Complete EnclosuresIt is uncommon for healthcare facilities to completely enclose patients in a separate room because the staff would have less visibility of their patients. However, complete enclosures offer great auditory privacy from circulation paths and other programs. Healthcare clinics are impacted by noise, speech privacy, speech intelligibility, and music. Noises can be masked or canceled out through ambient sound generated electronically. These noise canceling devices can be integrated so as to be unnoticeable. Architectural elements such as dropped ceiling baffles and additional acoustic

material can further control voice levels. Music can also contribute to acoustical privacy as well as having a positive effect on a patient's health.

99c Company

127


Primary Circulation

Lower Light

Levels

Lower Ceiling

Fixed SeatingImplied Threshold

Adjus

table Divider

Barcode Office

128


ENVIRONMENTAL FACTORS

Natural LightingWhere possible, natural lighting should be provided. A shading device should be accessible to patients so that the amount of light can be adjusted. Patients will generally feel more positive about their experience and well being if they have a sense of control over their physical surroundings. Waiting without any distractions or activities to keep oneself busy creates a sense of powerlessness.

Artificial LightingPrivate areas should have lower light levels. Patients who feel they have no control over their waiting time and left with nothing to keep themselves busy may perceive their quality of care more negatively. Another way for patients to have control over their environment would be to provide them with adjustable task lighting. Innovative lighting systems at Schipol airport have been implemented which automatically dim or turn off when the boarding process is underway or the gate is not in use.

Schiphol Airport

129


Werribee Mercy Hospital

130


Designated ColorsVinyl floor finishes perform well with regard to stain resistance, underfoot comfort and safety, low maintenance, durability, and good acoustics. Multiple colors are used in floors to enrich design features and meet patients' psychological needs. Meandering designs on corridors are architectural elements for guidance regarding patient flow. The circular space at the nurse station and waiting area create a stop point for patients with hints of personal boundaries to be respected.

Centrifugal seating arranged adjacent to the main architectural element is intended for strangers to reduce eye contact and contagion risk.

Children's Hospital of Alabama

131


The Royal Children's Hospital

132


Natural ElementsWindows with views of nature can provide a form of distraction to those who enjoy viewing pleasant natural scenes. Attractive views provide the patients relief and pleasure. Indoor natural elements such as atriums, greenhouses, planters and window boxes also allow for the users to benefit from the natural view without leaving the building.

Children's hospitals are adopting family friendly policies to make an often painful experience less traumatic for parents and children. An aquarium in the waiting space of The Royal Children's Hospital affords a good distraction.

Children's Hospital of Philadelphia The Royal Children's Hospital

133


The Royal Children's Hospital

134


Arts for HealthcareNature could also be represented in the waiting room in the form of interior-design elements, such as color, furniture, carpet, and painting.Art, including scenes of natural elements, could help to reduce stress and anxiety. Nationwide Children's Hospital in Columbus, Ohio, has a 'Magic Forest' in the main lobby. The arts are recognized as a powerful tool to aid patients and families dealing with challenging circumstances. The Society for the Arts in Healthcare reports that roughly half of US hospitals are using the arts to support the well being of patients, families, and staff, to create a healing

environment, and to lower stress and anxiety. A variety of art works such as sculpture, glass, kinetic and lighted works fill the hospital with visual delight. In clinical settings, art work is used by staff to help distract and relax patients so that procedures go more smoothly.

Nationwide Children's Hospital The Royal Children's Hospital

135


Nationwide Children's Hospital

IDENTIFYING PATTERNS

The physical setting affects a patient's health. Reduced stress results in improved healing. This comes from a sense of control over one's environment with a key component being confidence in the privacy offered in rooms where medical questions are asked and care is administered. An added benefit is that less stressed patients will contribute to less stressed staff.

136


138

For patients satisfaction, healthcare givers such as CVS Health MinuteClinic should synthesize both their physical and psychological needs. For the physically handicapped, MinuteClinic should guarantee wheelchair access, have the text on signage and computer screen easy to read, and have the appropriate tilt angle of the computer screen for people in wheelchairs. Wheelchair seating should be offered in waiting areas, and the bathroom should meet the needs of ADA. The majority of patients congregate in groups such as parents with children.

When patients walk into the MinuteClinic, they should feel comfortable in the environment. Amenities are important, but an emotional connection as well as a physical connection must be made. When receiving the next patient in the waiting area, the NP could come and greet the new patients at their seats by saying, I will be with you soon. It conveys the sense that We know that you are here. For those who have chronic medical conditions, their relationship with the NPs are more prolonged, and they will be more satisfied if they feel the NPs are compassionate.

PATIENTS SATISFACTION IN WAITING


139

Privacy and Data SecurityGiven the rapid digitization of sensitive information, privacy and data security is a universal concern. They have become the new drivers of brand and reputation for healthcare suppliers. In order to retain current patients and attract new ones, businesses must demonstrate that they are engaged with the issue on a daily basis and in a meaningful way.

A patients needs for privacy varies for each individual. Some people think installing video surveillance cameras in public places is a good idea because they may help security. Other people think this a bad idea because surveillance cameras may infringe on peoples privacy rights.

Visual privacy also impacts willingness to disclose sensitive information. When answering a questionnaire, those who value privacy passed on nearly 2x more sensitive questions when they did not have a visual privacy on a computer compared to those who did.

A majority of people report either no change in the security of their data or that their data is less secure than it was five years ago.

Who valuesvisual privacy

more?

Peoples attitude towards video surveillance cameras

No changeor

less secure

57%

63%

19% 18%

Good Idea Bad Idea Not Sure

% Men

%

AGE 18-26 26-35 36-45 46-55 55+

6559615249

50 61% Women

More Secure

43%

WITHVISUAL PRIV ACY

WITHOUTVISUAL PRIV ACY

5.5 9.2Passed Questions

withvisual privacy

withoutvisual privacy


140

% of the most highly engaged employees value work environment that allows them to:

the consequences of distraction:

98% 97% 95%

97%95%88%choose where to work

within the ofce,based on their task

concentrate easily

feel relaxed, calm

greely express andshare ideas

feel a sense of belongingto their company and

its culture

work in teams withoutbeing interrupted

11 23 5 11MIN FOR INTERRRUPTIONS

When we try to work on aproject, we get interruptedevery 11 minutes(on average).

MIN TO RETURN TO FLOW

When we get interrupted,it takes us up to 23 minutesto get back into FLOW-the state where we aredeeply engaged.

IQ POINTS FORMULTI-TASKING

When women aremultitasking cognitivecapability is reduced to5 IQ points

IQ POINTS FORMULTI-TASKING

When men are multitasking cognitivecapability is reduced to 15 IQ points

WORKING ENVIRONMENT


141

Viewable angle 140o

Display

Ideal Working EnvironmentA survey conducted by the global research firm IPSOS shows a strong correlation between employee satisfaction with their work environment and their level of engagement.

Only 11% of respondents were highly satisfied with their work environment; they were also the most highly engaged. These respondents agree their workplace allows them to:

The Consequence of DistractionResearchers work has proven that any belief that people can successfully multi-task is essentially wishful thinking. Humans can give controlled, full attention to just one thing at a time. When we try to pay attention to any two memory-dependent tasks at once, were easily distracted and end up doing neither one well.

Problems of the Open Door PolicyWithout question, successful interaction between patients and NP requires easy access to each other. But it also requires giving NP the time and place to focus. Having NPs back and computer screen exposed to the corridor shows neither welcome patients nor delivery enough privacy for NP as necessity. It may also leave patients personal information vulnerable to unwanted prying.


142

Medway. MA

CASE STUDIES


Wellesley, MA

143


144

Didicated space for waiting in CVS minute clinic Didicated space for waiting in a ave hospital

Comparing a Minute Clinic waiting rooms primary components to a typical healthcare facilitys waiting area components. First, note the diagram at the left shows the average space given to a waiting area in a CVS Minute Clinic. In addition to the average number of visitors. Same info provided for a typical health care facility. The diagram to the right shows a comparison between these two models. At the top of the red line, you can see the provided (quantity) for each particular component at a typical health care facility. To the bottom of the line is the quantity provided for each component at a Minute Clinic waiting room. Seating, restrooms, reception, kiosk, and entertainment are the components condsidered in this analysis.

Ave. Healthcare Wait

Minute Clinic Wait

Seating In an average healthcare facility, 15+provided for visitors. Where in Minute Clinic provide at max 4-5seats for visitors.

ReceptionIn an average healthcare facility, reception deskprovided for visitors. visitors.

Kioskin a minute clinic a kiosk replaces the need for a reception desk.

EntertainmentIn an average health carefacility, TV provided forvisitors. Where in Minute Clinic very minimal entertainment provided.

COMPONENTS

Wellesley

Here is a comparison between MinuteClinic waiting rooms primary components to a typical healthcare facilitys waiting area components. First, note the diagrams below showing the average space given to a waiting area in a CVS Health MinuteClinic and a typical healthcare facility. The diagram to the right shows a comparison between these two models. At the top of the red line, you can see the provided (quantity) for each particular component at a typical healthcare facility. To the bottom of the line is the quantity provided for each component at a MinuteClinic waiting room. Seating, restrooms, reception, kiosk and entertainment are the components considered in this analysis.

Dedicated space for waiting in CVS minute clinicDedicated space for waiting in a avg hospital

Avg. Healthcare Wait

Minute Clinic Wait

Seating In an average health care facility, 15+ pro-vided for visitors. Where in Minute Clinic provide at max 4-5 seats for visitors.

RestroomsIn an average health care facility, gender Specic restrooms, 2+ pro-vided for visitors. Where in Minute Clinic provide at max 1 bisexual restroom provided for visitors.

ReceptionIn an average health care fa-cility, reception desk provided for visitors. visitors.

EntertainmentIn an average health care facility, TV provided for visitors. Where in Minute Clinic very minimal entertainment provided.

COMPONENTS


145

Didicated space for waiting in CVS minute clinic Didicated space for waiting in a ave hospital

Comparing a Minute Clinic waiting rooms primary components to a typical healthcare facilitys waiting area components. First, note the diagram at the left shows the average space given to a waiting area in a CVS Minute Clinic. In addition to the average number of visitors. Same info provided for a typical health care facility. The diagram to the right shows a comparison between these two models. At the top of the red line, you can see the provided (quantity) for each particular component at a typical health care facility. To the bottom of the line is the quantity provided for each component at a Minute Clinic waiting room. Seating, restrooms, reception, kiosk, and entertainment are the components condsidered in this analysis.

Ave. Healthcare Wait

Minute Clinic Wait

Seating In an average healthcare facility, 15+provided for visitors. Where in Minute Clinic provide at max 4-5seats for visitors.

ReceptionIn an average healthcare facility, reception deskprovided for visitors. visitors.

Kioskin a minute clinic a kiosk replaces the need for a reception desk.

EntertainmentIn an average health carefacility, TV provided forvisitors. Where in Minute Clinic very minimal entertainment provided.

COMPONENTS

WellesleyWellesley, MA

146

Didicated space for waiting in a ave hospital

Comparing a Minute Clinic waiting room traveled distance to surrounding functions to that of a typical healthcare facility. First, note the diagrams at the left shows the average space given to a waiting areal in a CVS Minute Clinic. In addition to the average number of visitors. Same info provided for a typical health-care facility. The diagram to the right shows in green distance traveled to nearby functions from a CVS minute clinic and the light gray is showing the same but from a typical healthcare facility waiting area. For instance the diagram illustrates how far the distance traveled to an outdoor view which is very furthest in a Minute Clinic compared to a very small distance from the wait area in a regular healthcare facility to an outdoor view.

Didicated space for waiting in CVS minute clinic

Here is a comparison between the waiting room travel distance to the surrounding functions in a CVS Health MinuteClinic and a typical healthcare facility. First, note the diagrams below that show the average space given to a waiting area in a CVS Health MinuteClinic. In addition to the average number of visitors. Same information is provided for a typical health-care facility. The diagram to the right shows in green, the distance traveled to nearby functions from a CVS Health MinuteClinic and the light gray is showing the same but from a typical healthcare facility waiting area.


WALKING DISTANCE


147

Didicated space for waiting in a ave hospital

Comparing a Minute Clinic waiting room traveled distance to surrounding functions to that of a typical healthcare facility. First, note the diagrams at the left shows the average space given to a waiting areal in a CVS Minute Clinic. In addition to the average number of visitors. Same info provided for a typical health-care facility. The diagram to the right shows in green distance traveled to nearby functions from a CVS minute clinic and the light gray is showing the same but from a typical healthcare facility waiting area. For instance the diagram illustrates how far the distance traveled to an outdoor view which is very furthest in a Minute Clinic compared to a very small distance from the wait area in a regular healthcare facility to an outdoor view.

Didicated space for waiting in CVS minute clinic


148

Signage, ceiling and lighting change

Floor change

Partial screen wall and half wall

Signage and tall vertical screens


149

Privacy CurtainPrivacy curtains are simple devices providing a measure of visual privacy on a temporary basis. The privacy curtains are frequently contaminated with potentially dangerous bacteria. There are several strategies to help deal with this issue:

1. Ensure the NP would have hand washing after pulling the curtain and before seeing the patient

2. More frequent disinfecting. The edges of privacy curtains with frequent hand contact should be cleaned and/or disinfected more frequently.

3. Using microbial resistant fabrics, and guarantee the polyester fabrics comply with the required NFPA 701 fire code


Medway

150

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1. The pharmacy counter and retail shopping are directly adjacent and provide no separation.

2. Exam room walls create clear separation between patients and the rest of the store.

3. Refitted exam rooms bump out into the retail area leaving no dedicated waiting area.

4. The kiosk faces the retail shopping space and provides no separation from the public

Wellesley


151

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5. The pharmacy waiting area is bounded by the back of a shelving unit

6. Walls 90 degrees to path beyond waiting area creates implied space dedicated to seating.

7. Doors adjacent to seating creates potential for exam room conversations to be overheard

8. Partial screen wall creates flanking path

1. Tall vertical screens perpendicular to patients direct conversation to those behind the counter.

2. Diagonal walls to retail shopping implies directionality for private conversations.

3. Shelving set parallel to the pharmacy creates implied threshold of counter service privacy.

4. Change in material on floor separates retail

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152

The L shaped healthcare department have MinuteClinic adjacent to pharmacy. However, the different decoration style and color coding isolate one from the other. Privacy of check in and waiting is limited. Only some visual privacy could be achieved by unaware block of sightline by shelves.

Medway

PATIENTS EXPERIENCE

arch7130_retail medical clinics_fall2014

Documents

types of cvs health

health insura

modes of health care

components of cvs health

cvs health minuteclinic

role of design

interior environment

graphic design wayfinding