Froedtert Hospital & Medical College of Wisconsin-Moorland Reserve Health Center, New Berlin, Wisconsin; Hammel, Green and Abrahamson, Inc. Photography © 2013 by Darris Lee Harris.

Chapter 1
Understanding the Patient Experience

Overview

Healthcare design has been changing rapidly in recent years. In the past this movement generally focused on supporting the workflows of physicians, with patients viewed as the individuals who were receiving care rather than as active participants in their own health and wellness. The design of clinics reinforced this formal relationship in an institutional, monochromatic manner. As recently as the 1990s, white walls, rows of seating, and buzzing fluorescent light fixtures were the norm.

Since 1984, when Robert Ulrich published the landmark "View through a Window" study in Science magazine, interest in the relationship between design decisions and patient health outcomes has steadily grown.1 More than a thousand studies have now been completed in the field of evidence-based design, which the Center for Health Design defines as the "process of basing decisions about the built environment on credible research to achieve the best possible outcomes."2

Five Stages of the Patient's Journey

A key strategy for approaching clinic design from the standpoint of patients is to envision what occurs at each step along the care continuum to determine how their experience can be enhanced by various aspects of the built environment. For years, design professionals have divided the patient's journey to, through, and away from a clinic into five stages: awareness, entry, assessment, treatment, and transition. These stages still provide a good basic structure for completing the research, planning, and design portions of a clinic project.

Awareness

The patient's journey begins with an awareness that he or she needs to seek care because of illness, injury, or need for routine appointments (e.g., an annual physical). Patients now have a variety of tools and resources to help them evaluate when they can address a condition through self-care and when they need to be examined by a healthcare professional in person.

Today, most clinics use the telephone, e-mail, printed postcards, letters, or text messages to remind patients that they should schedule a clinic visit to obtain preventative care services. When patients are not sure of what level and type of care they need or where this should be provided, they can use resources provided by insurance companies and healthcare organization, such as:

• Phone triage: patients can call a phone number anytime day or night, during the week or on weekends, to discuss symptoms and other health concerns with a healthcare professional and obtain advice. The nurse or other care provider determines how serious patients' health issues are and guides them to appropriate care.
• Online chats and websites: Some organizations that provide nurse-line or other phone triage services also offer the option of "chatting" with a healthcare professional online in real time. For example, in addition to calling OptumHealth's NurseLine, patients who are covered by the UPlan Medical Program can gain access via phone to Optum's library of prerecorded health messages or chat online with a nurse who can display web pages and recommend other resources as the discussion progresses.3
• E-visits and consults: Some insurers have begun to reimburse clinics that provide certain examination and consultation services via the phone or a video connection. For example, Blue Cross and Blue Shield of Minnesota offers patients the option of interacting live with a doctor who discusses symptoms, provides a diagnosis, and, if needed, can prescribe medications for a limited range of health conditions, such as coughs, colds, flu, headaches, bronchitis, stomach aches, allergies, and sinus problems, as well as ear, eye, and urinary tract infections.4

Entry

Orientation, shading, fenestration, location, and design of the reception/check-in area and wayfinding can all influence how comfortable patients feel as they approach and enter a clinic.

Orientation

Design professionals must take the climate and site conditions, natural and built environment, and connections to the community into account when determining the ideal orientation for a clinic's main public entry.

For example, the main entry to the Innovis Health Facility in Fargo, North Dakota, faces northwest in a northern climate. Although this orientation was necessary to relate the main entry to existing thoroughfares, it made keeping the cold air out of the entry atrium and adjacent areas during the winter a challenge. The architects responded by designing a long entry corridor with a side entrance that places exterior entry doors 60 feet away from the lobby.

Shading and Fenestration

Patients approaching the main entry can be set at ease when they can observe the activities that occur within a building. People who have entered the clinic can also use views through windows to identify interior and exterior landmarks that they can use to orient themselves as they plot a path to a specific destination.

Natalie Office Building
Tulsa, Oklahoma

The grand roof forms crowning a four-story atrium of this healthcare complex clearly announce the location of the main entry while providing shade for the tall glass curtain walls. The shading helps mitigate heat gain in a warm climate, while the glazing optimizes views. A canopy extends over the vehicular arrival and departure area to provide additional shelter from the elements and highlight the specific location of the entry doors (Fig. 1-1).

Reception and Check-in

Since the reception and check-in area is usually the first place where face-to-face interaction with staff occurs, it should be easy to find and be welcoming so that patients can efficiently and comfortably provide identification and insurance information, update health history data, pay required fees, and submit any diagnostic or lab test results that care providers need to review in advance of an exam. Since reception and check-in areas are highly trafficked, finishes and furnishings should also be durable and easy to maintain.

Clinic reception desks are typically located near the facility's main entry and patient drop-off area-and, ideally, have access to natural light and exterior views. Reception or check-in desks for specialized clinics can also be located near subentries or near elevator banks within a healthcare complex or medical office building.

Design professionals consider the proximity of the reception desk to seating in main lobbies or subwaiting rooms because patients generally prefer to sit where they can easily hear their name when it is called. Since patients do not like to have to cross high-traffic circulation paths, design professionals also address the relationship of the reception desk to entry and exit paths from the clinic's examination room area.

Figure 1-1: Natalie Office Building, Tulsa, Oklahoma. Clustered organic-shaped canopies and decorative metal support structures were designed to replicate trees. The shading from these canopies acts as a sunscreen for the glass and provides weather protection at the main entry. Additionally, the graceful canopies aid in wayfinding by clearly delineating the main building entry.

Photography © by Gary Zvonkovic

Apple Tree Dental
Minneapolis, Minnesota

This nonprofit dental healthcare organization strives to create a clinical setting that conveys a respect for the patient's time while being relaxing and calming to the senses. The patient experience begins with listening and answering questions. Patients pass through the main entry into a waiting area that has been designed with richly colored walnut veneer accents and comfortable lounge chairs and is flooded with natural light.

Those coming for an appointment are met by a greeter who is familiar with the personal preferences and health history of each patient. All check-in and checkout processes are completed in enclosed "navigation rooms." This allows a patient and dental professional to privately discuss any health concerns, customize treatment to meet the patient's specific needs, discuss insurance coverage and payment plans, and review the postclinic care plan. A toothbrushing station is also provided for patients who would like to use this before a checkup or procedure (Fig. 1-2).

Figure 1-2: Plan of Apple Tree Dental, Mounds View, Minnesota. Apple Tree Dental greeters meet patients as they enter the clinic and are taken to a private room, where all check-in processes are handled by the patient's navigator in private rather than at a public reception desk. The goal for Apple Tree is to make sure clients feel that they are given respect, that their needs and concerns are heard, and that they are treated as individuals.

Image courtesy of Hammel, Green and Abrahamson, Inc.

Assessment

Once patients decide to be examined in person by a healthcare professional, they must choose which clinic to visit. Patients with insurance typically start by checking to see if a clinic is within an approved network of providers, while those who are underinsured or uninsured often seek care at safety-net clinics that have a mission or legal mandate to provide healthcare services regardless of individuals' ability to pay.

Several qualities of the built environment also shape patients, decisions about where to seek care. These...