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2EBIRTHOFACLINIC A design workbook for architecture in general practice and primary care


#ONTENTS Acknowledgments

4

Foreword

5

Introduction

6

Why bother?

7

The fears

9

D.E.S.I.G.N. – A way of thinking about the architectural needs of general practice

22

Hovering above our community Zoning/land use 25

Transport

43

26

Service access

43

Safe

27

Our community – demography

44

27

Our community – cultures and subcultures

45

Our community – a needs analysis

46

Safe for staff Safe for patients

27

10

Checklist of principles for safety

28

For staff

10

What is design?

10

11

43 43

Efficient

10

For the bottom line

41

Diverse

For patients

The benefits

Our community

Innovative

29

Green

30

Neighbourly

31

The scope of architectural design

13

The big picture – health trends

The design process

13

Trends in morbidity

33

Our practice

50

The feel, character, culture and style of our practice

52

The function and operation of our practice

53

Our practice – its life stage and maturation

54

The whole is greater than the sum of the parts

56

35

Adjacency

56

13

Health promotion and disease prevention

35

Orientation

56

Do the groundwork first

13

Chronic disease

35

Overall functional issues

56

Create inclusive, accountable leadership

13

Mental health and wellbeing

36

Be a bower-bird

14

Indigenous health

36

See design as a ‘wicked problem’

14

Changes in health technology

37

14

Increased demands on the workforce

37

Think ‘long term’

Multiple ‘bottom lines’

Metaphors

19

Meetings between experts

19

Metaphor – practice as developing person

20

Metaphor – practice as participant in a network

20

Metaphor – practice as an embodiment of culture

20

Increasing attention to occupational violence and safety 37 Changes in the models of health care

38

Patient centred care

38

Lean thinking

38

Greater teamwork

39

57

Appraisal of the options – stay or move

58

Looking at our current place – impressions

58

Looking at location – growth

58

Location – amenity

58 Rebirth of a clinic

Design as a dialogue among experts 17

Bigger is not necessarily better

2


#ONTENTS

Working with an architect – managing a project Working with an architect

59

The specifics – spaces that have identified purpose

68

61

Entrance

70

Finding your architect

61

Reception area

71

Finding the right architect

61

Patient waiting area

74

Consulting rooms

76

The stages of the project

61

Feasibility and briefing

61

Other consultants

61

Schematic design

62

Design development

Treatment room

79

Observation area/ward

82

62

Sterilisation area

83

Design approvals

62

Computer/server room

84

Contract administration

62

Stock/storage room

85

Cost control

62

Managing time

63

Mothers/fathers room

86

The architects’ fee

63

Toilets/shower

87

Kitchen/staff room

88

Meeting rooms

89 90

Evaluation

64

Evaluation

66

Library/education area

‘Context’, ‘mechanism’ and ‘outcome’

66

Car park/alternate transport (bike/scooter) parking

91

Garden and paths

92

The Living Lab

67

94

References

95

ISBN 978-0-86906-289-0 This workbook was authored by Ian Watts (RACGP), Graham Crist (RMIT University), Judy Evans (RACGP) and Brendan Jones (Antarctica Group Pty Ltd Architects and Designers) Graphic design by Patricia Tsiatsias Disclaimer This publication has been devised to assist general practitioners who may be considering renovations or rebuilding the physical environment where primary care is dispensed to their patients. It is hoped that in providing some ideas put to us by experts and others who have been through the process that this publication may be useful in drawing attention to the multifarious considerations that should receive the attention of your own professionals. It is hoped that this publication may assist you and professionals engaged by you in the formulation of concepts when designing the physical environment in which you practice. On no account should this book be relied upon, nor is it intended as, a substitute for advice of professionals trained in the relevant fields. No liability will arise as a consequence of reliance on this publication. This material is printed using vegetable based inks onto 100% recycled stock.

Rebirth of a clinic

Resources

© The Royal Australian College of General Practitioners

3


)NTRODUCTION

When we set out on the task of designing this guide, we wanted to achieve three things. We wanted to develop something practical. We wanted to create something which reflected the current challenges for general practices – their increasing size and multidisciplinary nature, their focus on excellence in education, the importance of safety for both patients and the people who work in the clinics, and the ongoing pressure to manage costs. We also wanted to engage as many people as possible, and thus harvest the wisdom of members of both the architectural and health professions. We hope we have achieved all three of these. Our work had a number of steps.

In late 2007, the RACGP provided a design brief for a second and third year design studio at RMIT and hosted a ‘design competition’ for those students. Effectively, this is a semester-long subject in which the students focus on a particular design challenge. Many of the images of designs shown here were produced in the RMIT Architecture Program studio ‘Rebirth of the Clinic’ with the architecture students, supervised by Graham Crist and Brendan Jones in 2007. The designs are at conceptual stage and are intended to demonstrate a particular approach to questions of primary care. We have used them to illustrate questions and ideas. In some places we have used them, consciously, to challenge preconceptions and existing thinking about general practices and primary care more generally.

Finally, we took the diverse ideas into general practices. We listened to the problems and aspirations of working doctors and their teams. We heard their stories of success and failure, and incorporated as much as possible into the final workbook. We’ve designed the workbook so that you can write on it, draw on it, paste into it – then use it as briefing document. We hope you enjoy using it.

Dr Huy Quoc An

Mr Graham Crist

Rebirth of a clinic

The project began with discussions among working GPs at the RACGP National Standing Committee – GP Advocacy and Support, about the ongoing demand for a contemporary and practical guide. These took on a greater urgency following the murder of Dr Khulod Maarouf-Hassan in 2006.

Forging the partnership between the RACGP and RMIT University’s School of Architecture and Design was our next step.

6


7HYBOTHER

The benefits

For staff

Just as medicine has increasingly moved toward ‘evidence based medicine’, health care design is increasingly guided by rigorous research linking the physical environment of hospitals to patient and staff outcomes, and is moving toward ‘evidence based design’.2

Practices that retain staff are likely to be those that have safe, well-designed working environments, and staff retention ultimately leads to better health outcomes for patients.

Studies reveal the profound impact of the physical environment on a wide range of areas, from patient outcomes and length of hospital stay to medical errors and staff stress.3 For patients Rigorous studies link design features (such as natural lighting, views of nature, and artwork) to improved patient safety, reduced stress, improved outcomes for patients, faster recovery, less pain medication, decreased sleep disturbance, and improved overall health care quality.2,4

Rigorous studies link a well-designed physical environment to: sÂŹ AÂŹREDUCTIONÂŹINÂŹSTAFFÂŹSTRESSÂŹANDÂŹFATIGUE sÂŹ ANÂŹINCREASEÂŹINÂŹEFFECTIVENESSÂŹINÂŹDELIVERINGÂŹCARE2 For the bottom line Best practice design can employ ‘passive’ features (eg. using particular materials to improve insulation or acoustics, consistent shelving layouts to reduce risks or error) that improve workforce productivity and reduce impact on the environment without the cost of additional staff and resources. Although there appear to be no published studies on the economic benefit of good design in general practice and primary care, a study on hospital design reported that the estimated savings (from reducing harm, for example) and revenue gains (from improved patient flow, for example) nearly recaptured the incremental investment in better building in one year.5

Well considered design can certainly produce efficiencies and enhance safety. Beyond that it can enhance the patient experience. If that experience is central to primary care, then it is worth bothering with.

Rebirth of a clinic

“Researchers have shown that health care buildings, equipment, furnishing, displays, signs, colors, art, landscape, and other sensory stimuli have a disproportionate impact on customers’ overall evaluation of the service provided by those facilities. However, most health care facilities have yet to incorporate the fruits of this research.�5

Magin and colleagues found that as many as 64 percent of GPs are exposed to work related violence in any 12 month period.6

10


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!WAYOFTHINKINGABOUTTHEARCHITECTURALNEEDSOFGENERALPRACTICE General practitioners and other health professionals in primary care often seek, consciously and unconsciously, to satisfy a number of demands within the designs for their practices. The mnemonic D.E.S.I.G.N. was developed to capture the characteristics that many GPs want to consider in designing or renovating a practice. Australian general practices are diverse. They want to be efficient. They seek to be safe for both patients and health professionals. General practice seeks to innovate. General practitioners are often keen to be ‘green’. General practice is a key part of a community, and a part of the neighbourhood in both a physical and abstract way.

Rebirth of a clinic

The mnemonic is not prescriptive, but rather a starting point for considering ideas that can be incorporated into the design process.

Image courtesy Fai’zan Shah

24


4HESPECIFICS¯SPACESTHATHAVEIDENTIFIEDPURPOSE

‘L’ or ‘U’ shaped desks allow the receptionist to turn away when giving personal information over the phone. More desk area is made available for easy reach. Typing desk height is lower than a general desk. Avoid having patient files in public view or a desk top at counter level. Air flow should not be directed toward the receptionist.

A suitable sized notice board should be placed in view of the entrance reception area. Chairs should be located 3 metres away from the reception desk.

Rebirth of a clinic

A suggested ideal section through the reception area showing hidden filing, correct reception desk design, and air pressurised to flow away from the receptionist.

Reproduced from The design of doctors’ surgeries, 1984

Combining a desk and counter provides a 360 mm higher counter to give privacy to the desk and a writing surface for the patient.

73


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Thought box

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Rebirth of a clinic

s¬ #ONSULTING¬ROOMS¬ARE¬NOT¬STOREROOMS¬A¬TROLLEY¬WITH¬MULTIPLE¬DRAWERS¬ON¬WHEELS¬ PROVIDES¬NECESSARY¬EQUIPMENT¬SUCH¬AS¬SWABS ¬SPECIMEN¬JARS ¬NEEDLES ¬AND¬SYRINGES¬ 4HE¬TROLLEY¬CONlGURATION¬IS¬THE¬SAME¬FOR¬EVERY¬CONSULTING¬ROOM¬A¬CLINICIAN¬WILL¬HAVE¬ ACCESS¬TO¬THE¬SAME¬EQUIPMENT¬NO¬MATTER¬WHICH¬ROOM¬THEY¬ARE¬WORKING¬FROM¬4HESE¬ TROLLEYS¬ARE¬RESTOCKED¬BY¬PRACTICE¬STAFF¬AT¬THE¬END¬OF¬THE¬DAY

77


REBIRTH OF A CLINIC (extract)