Description
Few components of the hospital have increased in size and importance as fast as the outpatient departments. In some countries, however, notably Germany, the services they provide are also offered outside hospitals, resulting in costly redundancies. Formerly limited to low-risk medical services, outpatient departments offer an ever-increasing array of interventions, including those that formerly required patients to remain in the hospital for several days. In 1980, American hospitals earned only 12 % of their revenue from medical services provided in outpatient departments; in the 1990s it had already increased to more than 50 %.[108] What distinguishes the outpatient department from the rest of the hospital is that even though patients return home after treatment, this part of the hospital has become the busiest (and therefore the most traffic-intensive), in part because patients rarely come alone. Friends or family accompany them and sometimes wait until the medical procedures are completed. The latter vary from interviews in consultation rooms to surgery, from simple diagnostic procedures to complex but (usually) low-risk interventions. Some procedures may take only a few minutes while others can last all day.
Martin Luther King, Jr. Outpatient Center, Los Angeles, HMC Architects, 2014. Reception and generic consultation rooms
Outpatient departments today contain extensive waiting areas, consultation and examination rooms, various types of treatment spaces and all the technology, supplies, logistics and other facilities required to run them. These can be designed as generic units suitable for various disciplines (general surgery, orthopedics, plastic surgery, internal medicine, rheumatology, etc.) specifically designed for individual disciplines (ENT, ophthalmology, urology, etc.), or thematically organized (mother and child center, oncological center, etc.). The thematic outpatient facilities are sometimes located near the corresponding hot floor functions. If inpatient wards are also needed for specific themes and situated close to the corresponding outpatient and hot floor functions, this may result in a layout reminiscent of the last generation of pavilion hospitals, which also developed as separate, self-contained units corresponding to specific medical departments. Large hospitals are sometimes organized in this way, which presupposes a robust and logical logistic structure enabling outpatients and visitors to find their way with ease through the entire hospital complex. Often, however, outpatient departments are organized and clustered together in units, usually running on an 8.00 am–5.00 pm schedule, separated from the other, 24/7 facilities of the hospital.
Orbis Medisch Centrum, Sittard, the Netherlands, Bonnema Architecten, 2011. This centralized waiting area serves several outpatient units, allowing a more generous space. An adjacent atrium provides daylighting.
Typical outpatients come to the hospital from home. General practitioners and other healthcare providers working outside the hospital normally supervise the part of the care pathway preceding the first outpatient visit, and they take over once the (multiple) trips to the hospital are finished. After having reported at the reception desk, the patient takes a seat in a designated waiting area. Waiting is often by far the most time-consuming ‘activity’ in this department. The overall layout of the hospital determines where the outpatient departments are located, whether or not they have a separate entrance and whether they are grouped together as a separate, self-contained cluster, as a specific zone in the hospital with dedicated outpatient units or as decentralized units spread throughout the hospital building. Very often, outpatient departments relate more closely to parts of the care pathway accommodated outside the hospital than to the parts within the hospital, which makes it feasible to build them as satellite clinics, integrated with other healthcare services in relatively small community health centers.
Academic Medical Center (AMC), Amsterdam, the Netherlands, Architectengroep Duintjer in cooperation with Dick van Mourik, 1981–1985. The photo shows the refurbishment of the waiting area in the AMC daycare center by Valtos Architecten. There is no longer a clear distinction between the waiting area and the reception desk.
The examination table is the heart of the outpatient department. It can be a generic or a very specific piece of equipment, depending on the requirements of the medical specialty involved. For example, the pediatrics department requires a consultation table designed for infants and toddlers, with reduced surface and increased height. Other departments, such as gynecology, require specialized examination tables, including leg support and adjustable back position. The placement of the examination table should be such that the medical staff is able to thoroughly examine the patient; it can be placed in a corner with two sides adjacent to the wall, with one side adjacent to the wall or free-standing, allowing for movement around the patient.
Spaarne Ziekenhuis, Hoofddorp, the Netherlands, Wiegerinck Architecten, 2013. This daylit waiting area emulates a hotel lobby.
The consultation and examination areas can function jointly in a combined specialty-specific or generic consultation room with or without internal partitions, or separately, with the consultation and examination rooms connected to each other by a door or by a (restricted) corridor. Each variant corresponds to a model of traffic flow — either separating or integrating medical staff routes with patient routes. In the consultation area, the medical staff have access to patient information and a working desk, where a great part of the conversation with the patient takes place. Equipment such as the examination table, instruments and disposables are needed in the examination area. A hand-washing facility in the examination area is mandatory. Mobile or fixed diagnosis and treatment equipment might need to be accommodated in the examination area for specific patient groups, for which exact specifications need to be made. The more generic the design of the consultation room, the more functions it can support. Windows should not compromise the patient’s privacy.
The unit comprises all the consultation and examination areas, along with the reception area, waiting areas and, potentially, the associated diagnostic and back-office facilities. The medical processes can be organized in a monofunctional manner, with segmented front-office functions per specialist, or in a multifunctional manner, allowing for interdisciplinary consultation and flexible use of front-office facilities. Digitized access to the patient’s complete health record must be provided.
An outpatient department can be set up in various ways. One option is the so-called ‘one stop shop’ model, where all the procedures take place in the same area of the hospital. In other cases, patients need to visit various places in the building — the outpatient unit itself, the radiology department for a CT scan and the laboratory for blood tests, for instance. Small hospitals, lacking advanced equipment, sometimes have to refer patients to better equipped facilities for specific diagnostic tests.
Here we will discuss four models for organizing the outpatient department, each featuring a different combination of the determining factors: availability of digital or paper-based information systems, location of the studies, administration and management offices, layout of waiting rooms, the level of specificity of the consultation and examination areas, the shape of the building and daylight accessibility.
The first model (A) uses the consultation and examination areas as a traditional ‘doctor’s office’. The level of digitization is usually low. The medical staff uses the consultation and examination rooms not only to consult with patients but also to study, do administrative work and conduct meetings. One of the advantages of this model is direct access to daylight from the consultation and examination rooms. While the layout is compact and seems efficient from the perspective of the medical staff, it may lead to inefficient and cumbersome process flows from the perspective of the patient and also from the perspective of the outpatient department as a whole. Waiting areas need to be close to the consultation rooms, positioned along the corridor, and therefore, more often than not, are deprived of natural light or, at times, located in special niches with direct daylight. Some outpatient units might have receptionists, usually stationed at counters in the waiting area to respond to patients’ queries and assist in tasks such as completing administrative forms. This activity within earshot of other patients can cause lack of privacy issues. The same corridor where the waiting area is situated might also be part of the route to other medical specialties, leading to difficult patient traffic flows.
Evolution of the outpatient department
A Monofunctional outpatient department
The consultation and examination room doubles as a medical specialist’s study, making it and the adjacent examination area(s) unusable by other disciplines outside the specialist’s consultation hours.
B Separate medical specialist’s study
The separation of the examination area from the medical specialist’s study allows for a more effective use of the consultation and examination rooms.
C Complete separation of front-office and back-office areas
The archive and back-office functions are situated outside the front-office area (consultation rooms, reception, waiting areas); the use of flexible, shared workspaces for medical specialists and assistants allows for better utilization and collaboration of both the front- and back-office facilities.
D Multifunctional outpatient department
With the advent of electronic patient records and centralized, digital appointment scheduling systems, the hospital no longer needs a paper-based patient record archive; interdisciplinary collaboration and workspace flexibility are facilitated by this model.
Example of a multifunctional outpatient department: configuration and traffic flows
The second model (B) groups the doctors’ studies, administration and management offices and meeting rooms in a separate area of the hospital, allowing the outpatient unit to be used exclusively for patient consultations. This model usually consists of a corridor with consultation and examination rooms on the sides and several decentralized waiting areas, with archives and back-office facilities between them. The reception desk is situated in proximity of the consultation rooms it serves, so that the process of making a follow-up appointment is still a rather public matter. All traffic flows could potentially end up leading through the same space, be it patients waiting for an appointment, patients going to a department situated at the end of the corridor or medical and support staff moving from one department to another. This combination of traffic routes can lead to disorientation and slowed-down processes. On the other hand, this model allows for direct natural light in all patient areas, with the exception of the corridor.
Process flows in the outpatient department are clustered in three functional areas: the consultation and examination room, the reception area and the waiting area. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.
The third model (C) situates the archive and back-office facilities near the doctors’ studies, administration and management offices and meeting rooms, instead of in the reception area. As a result, all activities not requiring the patient’s presence take place in a separate area to which they have no access, thereby strictly separating back-office medical staff traffic from patient traffic. Restricted corridors might improve the access of medical staff members to each other and to the administration and management area, allowing for better collaboration and eliminating the need for staff to walk through the waiting rooms and public corridors.
This model usually consists of a double-loaded corridor, with consultation and examination rooms of various medical specialties positioned on the sides. However, each medical specialty has an individual reception desk and waiting area, separated by the main traffic corridor. Traffic routes of patients and medical staff are separated. This allows for fast access to various back-office areas. Direct natural light is available in the consultation room; however, the corridors and the examination rooms receive little or only indirect natural light, due to their flanked position.
Monofunctional/specialist-centered vs. multifunctional outpatient departmentThe multifunctional outpatient department optimizes processes from a patient-centered perspective, resulting in fewer steps in the patient process, reduced waiting times, better quality of care and lower costs.
The fourth model (D) is based on the use of fully digitized patient records, permitting a high degree of flexibility in the location of the waiting areas, the back-office facilities, doctors’ offices and centralized reception and waiting areas. Although these larger waiting areas could increase the risk of patient-to-patient infection, this layout, when well-designed and well-managed, could facilitate greater patient comfort and privacy, faster traffic and easier access. This model usually consists of a double-loaded central corridor and two lateral corridors for patient traffic, with examination areas connected to a restricted access corridor for the medical staff. The patient arrives at a centralized front desk and is directed to the central waiting area. Access to daylight in the corridors is achieved by the use of internal courtyards and skylights.
Consultation and examination room with typical components: the consultation area (beige) with additional room for accompanying persons and walkers/wheelchairs (green), the examination area (orange) and the doctor’s workspace (purple); the archive is a component specific to outpatient departments functioning without electronic medical records.
Footnotes
‘Ambulatory care design, professional offices, and bedless hospitals’, in Richard L. Miller, Earl S. Swensson, J. Todd, Hospital and Healthcare Facility Design, New York, London: W. W. Norton, 2012 (third edition), p. 250.
Drawings
Evolution of the outpatient department A Monofunctional outpatient department The consultation and examination room doubles as a medical specialist’s study, making it and the adjacent examination area(s) unusable by other disciplines outside the specialist’s consultation hours. B Separate medical specialist’s study The separation of the examination area from the medical specialist’s study allows for a more effective use of the consultation and examination rooms. C Complete separation of front-office and back-office areas The archive and back-office functions are situated outside the front-office area (consultation rooms, reception, waiting areas); the use of flexible, shared workspaces for medical specialists and assistants allows for better utilization and collaboration of both the front- and back-office facilities. D Multifunctional outpatient departmentWith the advent of electronic patient records and centralized, digital appointment scheduling systems, the hospital no longer needs a paper-based patient record archive; interdisciplinary collaboration and workspace flexibility are facilitated by this model.
Example of a multifunctional outpatient department: configuration and traffic flows
Process flows in the outpatient department are clustered in three functional areas: the consultation and examination room, the reception area and the waiting area. The processes are described from multiple orientations: the patient, the medical staff, facility services and information flows.
Monofunctional/specialist-centered vs. multifunctional outpatient departmentThe multifunctional outpatient department optimizes processes from a patient-centered perspective, resulting in fewer steps in the patient process, reduced waiting times, better quality of care and lower costs.
Consultation and examination room with typical components: the consultation area (beige) with additional room for accompanying persons and walkers/wheelchairs (green), the examination area (orange) and the doctor’s workspace (purple); the archive is a component specific to outpatient departments functioning without electronic medical records.
Photos
Martin Luther King, Jr. Outpatient Center, Los Angeles, HMC Architects, 2014. Reception and generic consultation rooms
Orbis Medisch Centrum, Sittard, the Netherlands, Bonnema Architecten, 2011. This centralized waiting area serves several outpatient units, allowing a more generous space. An adjacent atrium provides daylighting.
Academic Medical Center (AMC), Amsterdam, the Netherlands, Architectengroep Duintjer in cooperation with Dick van Mourik, 1981–1985. The photo shows the refurbishment of the waiting area in the AMC daycare center by Valtos Architecten. There is no longer a clear distinction between the waiting area and the reception desk.
Spaarne Ziekenhuis, Hoofddorp, the Netherlands, Wiegerinck Architecten, 2013. This daylit waiting area emulates a hotel lobby.
Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.