Room to Grow

"Time is that wherein there is opportunity ..."

Can you identify the wise man who uttered these words? It was none other than Hippocrates, perhaps best known for penning The Physician's Oath. And his take on the value of time is particularly pertinent to physicians today, who are seeing an estimated 50 percent more patients than just a decade ago -- while their compensation continues to shrink.

Most physicians can identify at least a few options for maximizing use of their time: they might try establishing a new scheduling technique, jotting hospital notes on a handheld computer, using e-mail to respond to nonurgent patient needs, or sending automated appointment reminders by phone. But how many have considered the way the physical layout of their office space affects their efficiency?

It's a concept that is not new to medical space planners, but one that physicians can be slow to recognize -- until they see the real impact a well-designed office has on their ability to work in a timely (and profitable) manner.

"I can't stress enough how an efficiently laid out office maximizes productivity," says Gail Lorenzen, a Southern Calif.-based consultant with The Sage Group. "We say it to our practices all the time and they act as if we are asking them to shoot the moon. But if we put the concept into dollars and cents, it works: If it takes the nurse 10 to 15 minutes to triage and prepare a patient before the doctor can come into the exam room, he could see two patients in that time."

"The physician's success is based largely on three parts. One is the physician's skills, another is a well-trained, motivated staff, and a third is having a well-designed facility," says Robert Moore, director of business development for HealthAmerica Realty Group in Atlanta, a firm that specializes in development, management, and leasing of medical office space. "You can have the right staff and the skilled physician, yet have a very unsatisfying medical practice because you are constrained by space problems."

Examine your exam rooms

Your exam rooms are, of course, where the bulk of your time (and the key to your business) takes place. If they are not organized for optimal use, your practice is losing time and money.

Richard C. Haines, president of planning and design firm Medical Design International in Atlanta, says his company helped one hospital-based multispecialty group in Fort Worth, Texas, increase its productivity by more than 50 percent in two months.

"The first thing we did for every one of those docs was design an exam room for each specialty," says Haines. "Once we had that room designed, we replicated it. For instance, an orthopedist would see a patient on a plinth, so that room is wider. A neurologist or other specialties would use a typical exam table, but the neurologist would almost definitely do a right-handed exam on the patient."

"When we lay out a medical suite, we are very careful to make every examination room the same," agrees Norm Lazerine, principal of Norman Lazerine Associates, a Los Angeles-based architecture firm specializing in clinical and medical office facilities. "The door's on the same side, the sink and cabinet are in the same place -- unless it's a special room for special procedures. We know that the doctor and his assistant are used to working a certain way, and if everything is in the same place it just helps to improve efficiency."

If sameness matters, so does size. "If the exam rooms are big enough for the specialty and the equipment," says Lazerine, "there's nothing much else that has to be done to those rooms. In the past, the trend was to have smaller rooms, because the physicians were trying to conserve space. But they found that, with additional equipment and a nurse in that room, and maybe a family member, it quickly became too small." Today, a 9-by-10-foot exam room seems to work for most physicians.

Lorenzen describes a dermatology practice she works with that has learned the "less-isn't-more" lesson. "Their exam rooms are so crowded that there's no room for their laser equipment," she says. "They are not making good use of this very expensive piece of equipment because of tiny little rooms. Instead, they have to roll the machine in and out, and it takes 15 to 20 minutes to set up a patient. In that time, they could have seen two patients and done two procedures to the tune of $300 to $500."

Long and winding hall?

Another of Lorenzen's clients is a general surgeon whose hospital is "enticing him to get space in the hospital." But she describes that space as "a huge, long hall of nothing but rooms all along. The nurses' station is at one end, the physician's office is at the other end. It is totally inefficient." Lorenzen says that, in a general surgery practice, the physician "needs small exam rooms very close together, so he can pop in and out, doing pre-op or post-op quickly."

The excess hallway eats up both time and staff energy. As Lorenzen says, "When there are lots of steps involved, you're going to wear out your nursing staff, and the doctor is going to be spending too much time going from one exam room to the next. That time really adds up if you're only spending 10 to 15 minutes with follow-up patients."

Haines offers an even more striking example of how poorly planned space leads to staff wear-and-tear -- and inefficiency. When his company assessed the design of a "huge facility" in the Midwest, he says "they had physicians walking about five miles a day in the original design. We reengineered their system so they were doing less than three. If you save a staff member from walking two miles a day, you pick up about an hour of time, which is then available for that doctor to see patients."

Lazerine agrees that "what's really critical is the corridor connecting everything together." When improperly planned, it is simply wasted space. But hallways can be put to good use, he says: "You can load them up - put shallow storage in them. It doesn't take much to grab a foot in depth, and instead of having a blank wall, you have floor-to-ceiling storage space."

"Physicians do tend to minimize the need for storage," Lorenzen says, even though many store long-term patient records off-site or on Zip disks. Hallway shelving is one practical solution for practices that are bursting at the seam with files.

On the business end

Speaking of bursting, have you sized up your business office lately? "Most physicians aren't looking at that area too much -- they're more interested in their exam area, their office area, their lab area," says Lazerine. It's important to think ahead, to consider what you have now, and what you'll need to have (in terms of staff and equipment) to meet your goals for growth.

"Whatever you plan for your business office," Lazerine advises, "know it is going to grow. What if you add another staff member or a piece of equipment? You have to find a location for your equipment, but also store what goes with it. It can take up 25 to 30 percent of the [business office] space."

Some physician offices are beginning to pay attention to the critical link between the business office and the waiting room -- where collecting payments, resolving insurance issues, and other key activities take place. "A lot of doctors are opening that area up," says Lazerine. "They want it more open, more approachable. The dilemma is, the staff aren't changing their habits. They're still talking about private issues, making telephone calls, and [their] conversations can be overheard [in the waiting room]."

He emphasizes that privacy issues cannot be overlooked in this part of the office, "especially when [practices are] bringing everybody into one space - you'll have a telephone operator, billing staff, receptionist, maybe a nurse. You have to do more than just open [the area], you have to then create pockets where there can be private conversations, like discussions about insurance and billing. The open office is great, but you have to have some security and privacy," says Lazerine.

And most office space experts agree: Avoid the sliding glass window at the reception or business office. "It instantly says to the patient, 'you're not important,'" according to Lorenzen. "The patient is the most important person there."

A room of one's own

If the patient really is the most important person in the office, how crucial is the physician's own private space? Not very, say the experts.

"The doctor himself doesn't need a huge office," says Tommy Tift, CEO of Atlanta's HealthAmerica Realty. "As physician groups are getting larger, more doctors are sharing that space." That may be a function of economy -- or of practicality.

"The doctors' consultation rooms have gotten smaller because rents have gotten higher," says Lazerine. "In many cases they are shared, depending on the physicians' schedules. A lot of physicians prefer to see patients in the exam area and not spend much time in their office at all."

For physicians who tend to spend more time than usual in consults -- for example, in an OB/GYN practice -- "we would be sure to put that office right near the exam rooms," says Haines, so the physician doesn't get pulled too far off the task of seeing patients.

Lorenzen agrees with this approach: "Physicians shouldn't be loitering in their offices -- they need to be out on the floor seeing patients. A lot of them think they need these luxurious offices, but this isn't where they need to spend their money and time."

And time, as Hippocrates said, is opportunity.

Joanne Tetrault, director of  editorial services for Physicians Practice, can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the Spring 2002 issue of Physicians Practice.