Urgent message: Making the best use of the space you have is not just a matter of comfort and esthetics; an efficient floor plan contributes to providing proper—and cost-effective—care and services.
Patrice Pash, RN, BSN, COHC
So you’ve signed the lease or purchased the property and you’re sitting there staring at this huge empty shell, dreaming of the potential finished space.
What will it look like? How many exam rooms do you need?
What additional offices might be necessary as the business grows?
It might seem like the simple answer is to hand off all these questions to your architect, but considering that many out there today have never been involved in designing or planning for a true urgent care center, you may find that your architect has as many questions as you do. Working together, you can certainly come up with a viable plan, but first you need to know what you need to be functional—now and into the future.
What happens when you find that four exam rooms are simply not enough during flu season?
Perhaps you’ve taken on a corporate client that sends you potential employees for drug testing and you realize that your one and only restroom is woefully inadequate. Failing to plan properly now may come back to haunt you later on.
One of the most common questions when planning is, how many exam rooms will I need? Logic might dictate that if you have a large enough shell to go ahead and build as many exam rooms as will comfortably fit.
However, on average, a single practitioner can effectively cover five or six exam rooms, with an additional one or two larger procedure rooms. Having more only allows you to stack up patients in the rooms during high-volume times; it does not alleviate patient flow issues. From a patient satisfaction standpoint, having to wait in a small, uninviting space almost certainly magnifies the irritation caused by the perceived wait. Most mature clinics find that having folks spend a blended time between the waiting room and the exam room conveys a sense of attention and movement.
If, however, your space allows and you will potentially have more than one practitioner available to work at some point, then it is common to increase the number of exam rooms to eight, and definitely plan for two procedure rooms. As a rule, most new clinics are building out something in the range of six to eight exam and two procedure rooms when possible. This number is almost always adequate to manage the volume of even the busiest facilities, five, 10, even 20 years into the future.
Now, a word about exam room size. On average, the typical exam room should be no less than 9 by 9 feet. This allows for the placement of a standard treatment table (32 by 72 inches), an accompanying patient chair, a typical cabinet/sink base combo, and a small writing desk for the physician. A room this size provides enough space for patient and family to be seen without feeling cramped. It also allows the practitioner to access the patient from nearly any side.
The procedure room is not just an overgrown exam room. You want to have a space that is conducive to managing everything from a laceration to a cardiac ar- rest, allowing for plenty of “elbow room” for addi- tional staff plus a larger sized gurney.
In addition, your procedure room tends to house a wider variety of medical supplies and equipment than the standard exam room. Many facilities will place their autoclave and their crash cart in this space, as well as casting and splinting materials. Planning for adequate cabinetry to store these materials is also important.
The sample layout pictured shows a procedure room that is approximately 13 feet, 5 inches by 9 feet, but in general allow minimally 12 by 12 feet for this space. Typically, procedure rooms will run in a line with your exam rooms, so the overall dimensions are often dictated by the wall-to-hall length of your exam room. Also allow for cabinets and counters when de- termining the overall dimensions. These will reduce the usable space by up to 25 ½ inches (standard counter depth).
The next area to consider when planning is the nurses station. Like in a well-run emergency department, the nursing area is the central nervous system of your clinic, the center of activity. Accessibility and storage are the hallmarks of a well-designed space. In addition, since it is the focal point for the other exam and procedure rooms, it is also wise to plan this space to occupy a place where you have “line of sight” to the majority of the treatment areas. Remember that in the early days of your clinic, staffing will most likely be minimal. Having the procedure room(s) located directly across from the nursing station will allow staff to monitor and react to any patients requiring greater attention.
Since a good portion of the nursing area is devoted to the management of the patient, attention to finishing this space is important. Your staff will re- quire an area to prepare injections, per- form certain lab tests, make and return phone calls, and dispense medications. These activities necessitate the inclusion of adequate counter space and cabinetry, which should be sufficient to contain a month’s worth of necessary supplies, such as needles, syringes, CLIA-waived tests, medications, and other patient care items.
Do not fall into the trap that “more is better.” While you can certainly argue that you can never have enough storage space, it is easy to over-order just to fill the empty cabinets you have. Also remember that staff will need workstations for computer access and phones to properly manage documentation, referrals, and patient call- backs. Minimally, planning for at least three work areas—one physician, one nursing, and possibly one x-ray tech—should be considered when designing the space.
It may seem like the work is done once the elements of exam, procedure, and nursing station have been ad- dressed. However, there are still some areas within your new facility that should be addressed in the planning stage.
For instance, will you be performing drug screen collections? If so, then assuming that you can adequately conduct these collections within the one patient-use restroom that is allotted to the floor plan could potentially lead to violations of Department of Transportation (DOT) drug testing guidelines.
The DOT states that the collection site must meet the following guidelines (49CFR Part 40.31):
“The first, and preferred, type of facility for urination that a collection site may include is a single toilet room, having full privacy door, within which uri- nation can occur.
“You must have a source of water for washing hands, which if practical, should be external to the closed room where urination occurs. If an external source is not available, you may meet this requirement by securing all sources of water and other substances that could be used for adulteration and substitution (e.g., water faucets, soap dispensers) and providing moist towelettes outside the closed room.”
The simplest way to meet these requirements is to create a dedicated restroom that is used solely for collections, and that has the toilet area segregated from the hand washing area and where toilet flushing is controlled externally. This can be achieved by the use of a remote hydraulic flush valve.
If space is a concern, installing a remote shut-off valve controlling the water supply to the bathroom when it’s being used for drug screen collection will make you compliant. However, this does not prevent the test subject from flushing the toilet. This could be addressed by the use of tankless toilets, or by securing both the tank and the handle.
Optimally, it would be advisable to plan for at least four separate restrooms within the floor plan: one for patients in the waiting room, one for general patient use, one for drug screen collection, and one for staff- only use.
Last, but certainly not least, you should put some consideration into the space dedicated for your radiology suite. While most reputable vendors will work with your architect on the design, layout, shielding, and electrical specifications of the unit you are purchasing, as a rule you should allot (minimally) an area that is 12 by 18 feet. At these dimensions, you will be able to accommodate a four-way float top table, as well as the standard wall Bucky and tech area for controls and processing. This is required equipment for performing computerized radiology.
If you choose to perform more traditional radiology, producing hard film instead of computerized images, then you will also need to allow for an additional 5 foot by 9 foot space for the dark room. This space, of course, should be devoid of any external light sources. You can trim down your installation costs by trying to place the radiology suite along an outer/ external corner of the facility. By doing this, you reduce the need to lead line/shield as many walls.
Other Spaces to Remember
While we’ve addressed the main clinical needs for a new clinic, there are still several other spaces that you must plan for. Spaces such as the reception/waiting room, a physician’s office, a utility/janitor’s closet, an IT room/closet for computer services, a break room for staff, and possibly other ancillary offices can be situated as the overall dimensions of the shell allow.
The reception area should be open and inviting, and allow staff to observe and communicate with waiting patients. The waiting room itself should offer easy access and ample seating. When planning the staff break room, remember that OSHA regulations dictate that the space used for consumption of employee food, drink, or personal items must be separated from any patient treatment areas. This merely means that you need to create a space that is separated by a closeable door.
Finally, remember storage. While much of your storage needs can be met by the appropriate use of cabinetry within the nursing area or exam or procedure rooms, items such as larger DME, crutches, etc., will require additional space. Storage for janitorial supplies, laundry supplies, and biohazard waste awaiting pick-up will all need to be considered.
In summary, with sufficient thought and planning toward the layout of your new facility, you can comfortably operate well into the future, secure that you have done the work early on to prevent problems and to maximize the efficient use and operation of the space. Work with your architect, and know what you need to effectively treat your patients.
Plan now and you won’t be remodeling later.