C A L I FOR N I A H EALTH C ARE F OU NDATION Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign March 2009 Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign Prepared for California HealthCare Foundation by Anjali Joseph, Ph.D., Director of Research Amy Keller, M.Arch., Research Associate The Center for Health Design Gowri Betrabet Gulwadi, Ph.D. Assistant Professor of Interior Design University of Northern Iowa March 2009 About the Authors The Center for Health Design is a research and advocacy organization of forward-thinking health care and design professionals who are leading the quest to improve the quality of healthcare through building architecture and design. The Center’s mission is to transform health care environments for a healthier, safer world through design research, education, and advocacy. More information is available at www.healthdesign.org. Gowri Betrabet Gulwadi, Ph.D., is an assistant professor of Interior Design at the University of Northern Iowa. Acknowledgments The authors wish to acknowledge the following individuals at The Center for Health Design for their contributions to this report: Callie Fahsholz, project manager, and Xiaobo Quan, Ph.D., research associate. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Introduction 4 II. Background 6 III. Findings: Literature Review Patient Outcomes Staff Outcomes Operational Outcomes Need for Future Research Literature Review Summary and Conclusions 1 4 IV. Findings: Best Practice Case Studies Access Waiting Exam Room/Procedure Space Ambient Experience, Information, and Technology Security and Privacy Spatial Relationship Staff Features Connection to Community Building Process 1 7 V. Design Recommendations. 2 0 VI. Conclusion 2 1 Appendix: Case Studies 2 2 Endnotes I. Introduction Evidence-based design links the A growing body of research shows conclusively design of the physical environment that the physical environment of health care facilities affects patients, staff, and families by impacting patient safety and quality of care. with an organization’s patient More than 1,200 studies conducted in acute care settings show that safety and quality improvement different aspects of the physical environment including noise, light, unit layout, air quality, and surface finishes impact outcomes such as agenda. Evidence-based design stress, falls, medical errors, and nosocomial infections. has been defined as the process of Recent meta-analyses of the physical features of health care basing decisions about the built facilities have primarily focused on acute care settings. Long-term care settings were examined in a literature review conducted in 2006 environment on credible research to by The Center for Health Design (CHD) funded by a grant from achieve the best possible outcomes. the California HealthCare Foundation (CHCF), which concluded that the physical environment plays an important role in improving clinical outcomes and quality of life for residents. There is some evidence that the physical environment plays an important role in outpatient settings as well. However, empirical information linking the design of outpatient settings — especially safety-net clinics (SNCs) — with patient outcomes has not been synthesized and analyzed, making it inaccessible to those making key decisions regarding SNC design and operation. Very few resources exist to support safety-net clinic design. Safety-net clinics encompass several different types of facilities, including county hospitals, outpatient clinics within public hospitals, and state, county, or private community health centers, among others. Defined largely by their mission to provide health care services to individuals and their families regardless of their ability to pay, SNCs continue to fill a very critical need in our health care delivery system by providing essential primary care and specialty care services to millions of uninsured patients. Many SNCs provide care in buildings that were built for other purposes (such as offices or residences) and later retrofitted as SNCs. These outdated buildings can impede care-giving processes, impact patient safety and quality of care, and contribute to dissatisfaction among patients and staff. Improved facility design can be a critical element in bringing about change in 2 | C alifornia H ealth C are F oundation the way health care is provided and experienced in safety-net clinics and other outpatient settings. This report summarizes the results of a research project examining how health care facility designs and various physical aspects of ambulatory care environments can positively or negatively impact patient experiences. The project included a review of literature examining evidence-based design in ambulatory care clinics (ACCs), and best practice case studies of community health center designs. This report is intended as a resource guide to help decision-makers involved in designing new SNCs or retrofitting existing SNCs create safer, less stressful, and more patient-centered care environments. The focus of this project was to understand the key issues involved in designing safety-net clinics, which comprise a subset of ambulatory care clinics (ACCs). While both ambulatory care and safety-net clinics provide a wide range of outpatient primary, medical, and surgical care services, including preventive (e.g., health check-ups) and curative (e.g., treatment for chronic diseases) treatments, SNCs are distinguished by their mission to provide services regardless of patients’ ability to pay. However, recognizing that research on ACCs is sparse and that research focusing on safety-net clinics is even more limited, the literature review looked at studies conducted within any type of ACC. Best practice case studies (conducted as on-site visits and phone interviews) were conducted at community health centers (one type of SNC) to supplement and strengthen the information obtained from the literature review. The case study findings along with the literature review provide a snapshot of the current state of ambulatory care design and provide a foundation for offering initial design recommendations and considerations for those involved in designing safety-net clinics. Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 3 II. Background Recent trends in the delivery of health populations. The variety of sources and consistency care services have seen a progression toward patient- of funding — especially for those clinics serving centered and family-centered initiatives, an increase underserved populations — influence these clinics’ in the use of medical technology, and new models accessibility, types of enabling services (e.g., of providing underserved populations with access interpretation services), and clinic policies.3, 4 In to quality health services. As health care shifts from addition to funding, community needs and licensing inpatient to outpatient services, and from treating regulations influence the types of services offered at episodic illnesses to a more longitudinal orientation, such safety-net clinics, often spanning a wide range primary care facilities are serving increasing numbers of preventive, primary care, and other services.5 of patients.1 The “medical home” model with its A new paradigm of ambulatory care is being effective focus on a regular source of care in a developed to shift from an older one-size-fits- familiar, comprehensive and coordinated system is all, reactive, and hierarchical approach focused increasingly influencing primary/ambulatory care.2 on sickness, to a more recent integrated, iterative Ambulatory care (referring to outpatient primary, patient-centered approach. (Recent efforts in medical, and surgical care services) is wide-ranging this regard include those at the Stoeckle Center and addresses both preventive care (e.g., health for Primary Care Innovation, and SPARC at check-ups) and curative treatments (e.g., treatment Mayo Clinic.) There is a corresponding shift in for chronic diseases). the construction and management of health care Ambulatory care occurs in a range of traditional facilities; trends show a shift towards ambulatory care and emerging settings including private physicians’ facilities. A 2008 report by the Healthcare Financial offices, urgent care centers, community health Management Association includes recent statistics centers, outpatient and emergency departments from Reed Construction Data on construction of hospitals, county clinics, and retail clinics, trends in the health care industry that project a among others. Ambulatory care clinics (ACCs) growth in new health care facilities by 14 percent in vary in the types and menu of services offered, 2008 with a steady increase in the coming years.6 In populations served, funding sources, and models addition, aging facilities are in need of updating and of care. Accordingly, there is a great variance in renovation to correspond with newer technologies required square footage, physical space needs, and operational styles. Overall construction costs for design, re-design, and management of ACC spaces. health care facilities run close to $35 billion annually; The physical design of ACCs reflects the overall these high costs prevail even as the health care design approach to care, can support or inhibit important industry addresses the need for optimizing costs functions that occur within ACCs, and influence the with flexible spaces and cost-effective evidence-based experienced quality of care. design approaches. A variety of for-profit and non-profit Research has begun to address the role of the ACCs across the United States serve a range of built environment in the overall ambulatory care 4 | C alifornia H ealth C are F oundation experience and as a component of the quality of care, of ACCs, envisioning new spaces responsive to the by focusing on patients’ accounts of their experiences new paradigm: flexible, multi-purpose, technology- in ACCs.7 Correspondingly, recent patient-centered enabled spaces that meet the needs of visitors and and family-centered initiatives in participating staff. practices are gathering information to see how best to But while the impact of physical clinic design improve patient and staff outcomes. on health outcomes has been established in other For example, the TransforMED home initiative long-term and acute care settings,10 it has not yet has whole-person care as a central goal, addressing it been documented in the ACC context. Examining through a culturally sensitive, community-oriented the relationship between physical design features and approach (www.transforMED.com). Key features clinic outcomes is especially needed at this time when include providing patients with an easily accessed the ACC market is redefining itself, and when ACCs “medical home” that becomes the starting point for utilizing newer models of care (e.g., care-team based) a continuous system of care, emphasizes quality and must sometimes operate in buildings designed for safety, and uses advanced data-based information traditional models of care (e.g., physician-based). systems. In a similar approach, the Advanced Medical Even as a burgeoning Internet creates immediate Home model is set forth by the American College and speedy access to health-related information of Physicians as “patient-centered, physician-guided, pertinent to ACC users, the information that cost-efficient, longitudinal care that encompasses and demonstrates how the physical environment impacts values both the art and science of medicine.”8 In this patient and staff outcomes in ACCs — particularly model, physicians are viewed as coordinators and safety-net clinics — has not been consolidated facilitators of a patient’s journey through the health meaningfully. The following review of literature and care system, providing care in a variety of settings best practice case studies aims to fill this gap. based on patient need and physician skills. At the core of such initiatives, among other features, is an increased emphasis on timely access to information and primary care access points, improved channels of communication between clinicians and patients, and continuity of care services, all of which imply a restructuring of the system, right from the ways in which ACCs are funded to the ways in which their physical spaces are designed and linked. Efforts that address a patient-centered approach have begun to explore the benefits of health information technology such as clinical electronic medical records9 or the portability of personal medical care information using USB technology. Part of this integrated approach also includes an examination of the physical environmental context Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 5 III. Findings: Literature Review Similar to past efforts in long-term and environmental factors, organizational factors, and acute care settings, this review of empirical literature interpersonal factors interactively contribute to the on ACC settings aims to provide evidence-based patient’s overall experience as represented in the guidance for future design and design research in conceptual framework in Figure 1. Because of the ACCs. Addressing a gap in the health care field, diversity of ACC types and functions, and because this review asks the following main question: the effort in this review is to find common features, Which physical features of ACC settings have the core of Figure 1 includes common experiential been associated with favorable patient, staff and features of ACCs as experienced by ACC patients. operational outcomes? Access Patient Outcomes Access issues address aspects such as a clinic’s Patient outcomes summarized in this section include geographic proximity to patients11 and internal patient satisfaction with the ACC experience, and factors within each facility such as the configuration other physiological and psychological outcomes of parking areas12 and ease of navigation within such as pain, anxiety, or stress during the ACC the clinic.13 When these elements were successfully experience. Patient outcomes in primary care addressed, positive patient outcomes resulted. In facilities are influenced by the type of clinic (who contrast, inaccessibility, non-availability of parking14 is served, and what type of services are offered), its and wayfinding problems due to symmetry of the physical attributes (location, configuration, and facility15 impacted patient experience negatively. spatial characteristics of the clinic), and experiential Streamlined approaches such as providing access to aspects of the patient’s clinic experience (duration multiple services in one-stop clinics were associated of wait times, attractiveness and cheerfulness of the with reduced short-term patient anxiety.16 waiting rooms, cleanliness, lighting, navigation and wayfinding, type of physician and physician-patient Waiting communication, personalization of services, anxiety The most significant aspect of patient experience and stress to availability of audio, visual and other and satisfaction in waiting areas was the time spent distractions in the clinic environment). waiting. Reducing wait times operationally and A patient’s clinic experience is a complex assembly implementing self-service kiosks to speed up the of multiple factors, starting from access to the clinic, registration process were associated with higher continuing through the exam room, and concluding patient satisfaction. Other aspects of the waiting with closure and exit procedures. The patient’s phase also impacted patient experience. Some experience in a clinic can be broadly categorized effective features included spatial boundaries that into five phases: 1) access, 2) waiting/registration, distinguished waiting areas clearly from any adjacent 3) examination, 4) procedures, and 5) discharge/ circulation paths17 or that clustered exam rooms in exit. In each phase, a combination of physical (built) a pod-like configuration.18 Within the waiting areas, 6 | C alifornia H ealth C are F oundation Figure 1. Conceptualization of Phases of Patient Experience Access Waiting Improve Positive Outcomes Consulting: Decrease Negative Outcomes Discharge Exam Exam Room Procedures Procedures Source: Figure used with permission from the Health Environments Research and Design Journal (www.herdjournal.com). physical and ambient properties also influenced as childrens’ play areas were found to help reduce patient experience: Cleanliness was associated with patient anxiety. However, this effect also depended higher patient satisfaction19 and areas rated with on the nature and content of the distraction — for higher physical attractiveness were associated with example, factors such as the usefulness of educational reduced anxiety, higher perceptions of quality of posters displayed in waiting rooms,24 age- care, and shorter perceived wait times.20 Similarly, a appropriateness of reading materials and activities,25 waiting area with a nouveau (non-traditional) style and the choice of hard toys (easier to clean and was associated with lower self-reported stress and disinfect) versus soft toys in play areas.26 higher patient satisfaction than a traditional style.21 Some research has examined the experiences of Presence of noise was negatively associated with individuals who accompany a patient to the clinic. patient satisfaction22 and a calm and quiet waiting Parents accompanying children to an outpatient bone area was preferred.23 marrow transplant clinic had mixed feedback to open The presence of waiting room distractions such waiting room in which staff members could assess as televisions, Internet or other diversions such children. Though parents strongly appreciated the Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 7 informal social interaction with other parents and Efforts to solve physical space issues in patients and preferred this setting to more traditional ambulatory care clinics have had mixed results. More settings, they had concerns about privacy and the positive outcomes were associated with collaborative comparison of their child with others.27 Informal efforts in which all or most staff members social contact in waiting areas also resulted in were involved in planning and implementing a therapeutic and learning outcomes.28 reconfiguration of the physical environment and related systems. Reorganizations that are imposed Examination and Consultation upon staff members with little or no input from the In the examination phase of an outpatient visit, staff are associated with less successful outcomes. clinician-patient communication is increasingly Of the existing research examining the effects mediated by the presence of technology. The spatial of layout and ambient conditions on performance organization of the room and orientation of the of staff, most has focused on accuracy and errors in computer screen with respect to the patient and filling prescriptions in pharmacies. While electronic clinician affected communication (e.g., allowing records are replacing handwritten records and cutting patient to see information on screen) and the sense down on staff tasks such as record pulling time, new of connection (e.g. reduced eye contact) experienced types of errors have emerged (e.g., a patient receiving by the patient.29 Because this phase is characterized by a prescription meant for another patient) requiring more waiting,30 the content of the distractions such as new vigilant skills among staff. Although rates of posters31 or age-appropriate reading material32 was a errors between handwritten and computerized were significant part of the experience. not significantly different, computerized prescribing with an advanced decision support system was Procedures recommended for checking dosage and frequency to In the procedures phase, some research explored the help reduce medication-related errors. need to consider visual and auditory privacy of the Another occupational factor of concern to the patient.33 However, most research has focused on the well-being of staff, especially therapists, is isolation sedative and analgesic use of different audio-visual experienced due to the nature of the occupation. In distractions.34 – 37 a study of 31 therapists in outpatient clinics in Israel, there was an inverse statistical correlation between Discharge work satisfaction and feelings of loneliness.38 Although the discharge phase is a critical component of the patient experience and establishes an Operational Outcomes opportunity for continuity of care, no research was Multiple factors mentioned in the earlier categories found pertinent to this phase. of patient and staff outcomes are closely intertwined with clinic-related operational outcomes. Examples Staff Outcomes of preferred outcomes include a confluence of factors Space and layout issues can affect staff by facilitating such as staff productivity, efficiency of operations, or hindering their tasks. The literature showed that higher productivity (more patients seen per hour), staff performance cannot reach full potential without and reduced cycle time (length of a patient’s a supportive physical and social environment. experience). 8 | C alifornia H ealth C are F oundation Efforts to redesign clinic operations implemented settings is associated with non-financial benefits at various sites are yielding post-redesign evaluation including quality of care, fewer medical errors, and data. Operational outcomes included the benefits better access to information.41 EMRs also offer space of decentralized nurse stations that helped reduce savings because storage of paper records is eliminated, wait times39 and using electronic medical records potentially reducing leasing costs.42 An underlying (EMRs).40 Implementing an electronic medical concern with EMRs is adherence to HIPAA record (EMR) system in ambulatory primary care regulations. Table 1. ummary of Main Findings and Implications for the Physical Design of ACCs Based on Phase of Patient S Experience Improved Positive Patient Outcomes A ccess • Geographic proximity and ease of accessibility associated with greater patient satisfaction.43 • Women-only clinic associated with higher satisfaction versus traditional clinics.44 • Clear signage and good connections between parking structure and levels of the facility associated with greater patient satisfaction.45 Cardiac catheterization, electrophysiology, pulmonary, vascular, ECG, cardiac stress testing, nuclear medicine, nuclear cardiology facilities. • One-stop clinic reduced short-term anxiety.46 Breast cancer clinic. • Wayfinding clarity easier and less confusing in facility with asymmetrical plan with views to the outside serving as cues for orientation.47 Waiting/Registration • Clear physical boundaries for waiting area, distinguished from adjacent circulation paths, associated with clarity in wayfinding.48 General practice clinic, pharmacy, X-ray facilities. • Self-service electronic kiosks tested at SPARC reduced time spent in lines.49 • Cleanliness associated with higher patient satisfaction.50 Internal medicine, surgery, ophthalmology, obstetrics/gynecology, pediatrics, Chinese medicine, otolaryngology, orthopedics, family medicine, and dermatology facilities. • Calm and quiet areas associated with higher satisfaction.51 Cardiac catheterization, electrophysiology, pulmonary, vascular, ECG, cardiac stress testing, nuclear medicine, nuclear cardiology facilities. • Educational posters depicting prescription-filling process associated with higher levels of satisfaction.52 Outpatient pharmacy. • Patient escorts individually greet and escort patients to and from procedure areas to mediate patient experience.53 • Distractions reduce anxiety.54 • Nouveau environment reduced anxiety more than a traditional environment.55 Neurology clinic. • Physical attractiveness associated with reduced anxiety.56 Gynecology, dermatology, gastroenterology clinics. • Open waiting enables informal social support.57 Pediatric bone marrow transplant clinic. • Reduced noise associated with greater patient satisfaction.58 Internal medicine, surgery, ophthalmology, obstetrics/gynecology, pediatrics, Chinese medicine, otolaryngology, orthopedics, family medicine and dermatology facilities. • Hard toys in waiting rooms/areas were associated with decreased infection risk when compared with soft toys.59 General practice clinic. E x a m ination /C onsulting • Clusters of exam rooms, work rooms, and support areas in a pod system associated with greater patient satisfaction.60 Surgical, respiratory and EMT clinics in a pod. • Availability of age-appropriate media/reading material associated with greater patient satisfaction.61 Pediatric clinic. • Educational posters are noticed but effectiveness of education through posters needs further research.62 Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 9 Table 1. ummary of Main Findings and Implications for the Physical Design of ACCs Based on Phase of Patient S Experience, continued Improved Positive Patient Outcomes, continued P roced ures • Clear signage and good connections between levels of the facility associated with greater patient satisfaction.63 Cardiac catheterization, electrophysiology, pulmonary, vascular, ECG, cardiac stress testing, nuclear medicine, nuclear cardiology facilities. • Audiovisual distractions associated with greater patient satisfaction.64 Colonoscopy. • Music induced sleep without sedatives.65 ECG, CT scan. • Music induced sleep faster and without sedatives.66 • Virtual reality distraction effective in reducing pain.67 Pediatric oncology treatment. • Virtual reality intervention effective in reducing symptom distress and fatigue.68 Breast cancer chemotherapy. • Views and sounds of nature effective in pain reduction.69 Bronchoscopy. Decreased Positive Patient Outcomes A ccess • Unavailability of parking associated with decreased patient satisfaction.70 Diabetes clinic. Waiting/Registration • Same waiting area for different age groups was not favored.71 Pediatric clinic. • Open waiting compromises privacy.72 Pediatric bone marrow transplant clinic. • Soft toys in waiting rooms/areas were associated with increased infection risk when compared with hard toys.73 General practice clinic. E xa m ination /Cons ulting • Thin walls and flimsy curtains compromise auditory and visual privacy.74 • Visual access to therapy areas compromises visual and auditory privacy of patient.75 • Computers in the room associated with perception of reduced eye contact.76 • Physical placement of exam room computers influenced sense of connection experienced by patient.77 Internal medicine/family practice. Improved Positive Staff Outcomes A ccess • Non-linear (circular) layout for pharmacy enables quicker efficient dispensing because of reduced distance traveled and time for filling prescriptions.78 E xa m ination /Cons ulting • Dedicated space for community health worker at site enabled successful intervention.79 Mental health clinic. P roced ures • Color-coded clusters/modules based on complexity of surgical procedure, surgeon scheduling, and surgery turn-around time was easier for staff.80 Outpatient surgery care unit. • Standardized dress code and educational posters for procedures helped staff training and acclimatizing to new workflow.81 Outpatient surgery care unit. 10 | C alifornia H ealth C are F oundation Table 1. ummary of Main Findings and Implications for the Physical Design of ACCs Based on Phase of Patient S Experience, continued Decreased Positive Staff Outcomes E x a m ination /C onsulting • No clearly demarcated space for community health worker at site compromised intervention and patient privacy.82 Mental health clinic. P roced ures • Signage dividing unit into pre- and post-operative areas to improve workflow created an imbalance in staff workloads.83 Outpatient surgery care unit. Improved Positive Operational Outcomes Waiting/Registration • Decentralized nurse stations helped reduce visit time.84 Pediatric clinic. • Electronic medical records (EMRs) enabled quicker access to patient files.85 • Identifying where patient waits in the waiting area on an electronic seating chart improved overall efficiency and protected patient privacy.86 Cardiac catheterization, electrophysiology, pulmonary, vascular, ECG, cardiac stress testing, nuclear medicine, nuclear cardiology facilities. • EMR use associated with positive financial return on investment.87 Decreased Positive Operational Outcomes A ccess • One-stop clinic not cost-effective.88 Breast cancer clinic. Physical Design Implications for Each Phase A ccess • Consider parking adequacy or alternate forms of transport; locate beside public transport routes. • Provide clear wayfinding cues. • Provide clear signage. • Avoid symmetry; distinguish areas by using color or materials for easier navigation and wayfinding. Waiting/Registration • Consider logical clusters of rooms if physical design permits. • Establish clear spatial boundaries for waiting areas undisturbed by circulation paths. • Physical attractiveness: use warm colors, easy-to-clean materials and finishes. • Provide distractions such as television, computers that can engage patients while they wait. • Demarcate different waiting areas based on age-appropriate waiting activities. • Minimize noise from scheduling or other visitor activities. E x a m ination /C onsulting • Organize exam room functions within flexible layout as much as possible to enable patient-clinician communication. • Consider appropriateness of posters on walls or reading material provided. P roced ures • Maintain auditory and visual privacy. • Enable audio-visual distractions as needed. Note: If relevant in more than one phase, finding is repeated. Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 11 Need for Future Research Literature Review Summary and A summary of the literature review presented above Conclusions illustrates that some findings do relate physical Overall, the physical environment of ACCs has been environmental features to ACC outcomes. However, associated empirically in the following ways with the findings at this time do not yet cluster into patient and staff experiences and outcomes, and with clear robust patterns that could immediately inform operational outcomes in ambulatory care facilities: design and management of ACCs in general and Spatial relationships (e.g., spatial configuration: community health centers in particular. While all symmetry or absence of it; adjacencies of spaces, efforts were made to expand the scope of the search clearly defined boundaries of spaces; interface and cast as wide a net as possible, it is clear from the with circulation axes within the clinic; and need current assembly of literature that the following gaps to reconfigure the function and type of storage exist: spaces), Although the research on waiting areas and wait Visual and acoustic privacy (e.g., visual access times is aimed at the patient experience, the to computer screens given the progression studies are conceived under an older medical towards electronic recordkeeping; levels of visual model of episodic illness in which care ends with accessibility of screens; HIPAA needs; adequacy the experience in the exam room of the ACC. of acoustical rating of walls), Therefore, there is an absence of research on discharge functions, which would typically create Physical attractiveness (e.g., appearance and closure for the visit and establish continuity of arrangement; lighting), care beyond the current episode. Ambient experience (e.g., noise, music and its The studies reviewed for this report do not positive effects; natural and visual distractions; address the staff perceptions of the patient areas audiovisual distractions; cleanliness; comfort; and or the patient-staff interface. For example, staff sensory characteristics) and, perceptions of the waiting areas or wait times Information (e.g., signage; educational and and perceived or actual impact on their daily informative posters). functions have not been explored. Because there is a wide variance in the types Despite these findings, the settings of the articles of ACCs — compare for example a hospital used in this review and their findings together outpatient department with a community health present a fragmented picture, revealing multiple center — the research collected in this report opportunities for future inquiry. A systems approach seems fragmented, making it difficult to transfer is recommended that reflects a conceptual framework the evidence directly to design. The first task emphasizing ACCs’ flexibility and adaptability, use of at hand would be to create a comprehensive technology, and connectedness — three concepts that typology of ACCs along with unique attributes are closely aligned with sustainable design principles. of each. This would identify gaps much more Operational outcomes have not been studied effectively and provide focused ways in which clearly and comprehensively as they relate to applied design research could be carried out. ACC design. There are many links that could be 12 | C alifornia H ealth C are F oundation studied — infection risk, for example, could be explored with perspectives of the janitorial staff and how the clinic design serves their needs, etc. Infection risk in buildings designed with sustainable materials (those that require little or no maintenance, e.g., concrete, brick) can be compared with others. Effects of daylighting, another sustainable design feature, could be explored with respect to physician and staff productivity, patient satisfaction and energy savings. Overall, while this review identified several gaps, it also shows avenues for many linkages with existing efforts in ACC design and the health care industry. In conclusion, this review can be used a stepping stone for more concrete investigations. Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 13 IV. Findings: Best Practice Case Studies To supplement the literature review Designing for the pedestrian not only included examining evidence-based ACC design, case studies locating the site near alternative transportation but were conducted at community health centers to also creating pedestrian friendly walkways, stroller compile best practices in SNC design. The physical parks, and locating bike racks at the entries. environment features and community attributes of Improving access also meant improving community health center facilities throughout the wayfinding. Many of the facilities utilized color and United States were examined through either on-site symbol signage to strengthen wayfinding throughout visits and/or telephone interviews with the clinics’ the facility. Not only was color used within the CEOs, clinic managers, facility managers, and board public spaces of the clinic/center (waiting areas, members. The facilities studied varied in size, services entries, community rooms) it was used within the offered, and the type of setting (rural, suburban, and exam rooms and clinic space to distinguish service urban). lines (e.g. women’s health, pediatrics). Informational From the on-site visits and telephone interviews, kiosks are also included to improve wayfinding; these common issues and attributes emerged. They kiosks, primarily located upon entry, provide patients included: the importance of clinic access, the and visitors with information on the building value of waiting spaces, features in the exam/ features and services offered. procedure room, providing an ambient experience, security, information and privacy, recognizing Waiting spatial relationships and staff features, ensuring a Overwhelmingly, the importance of multiple waiting community connection, and understanding the spaces was evident among the safety-net clinics building process. visited and interviewed. Among these facilities, multiple spaces such as consult rooms, community Access conference rooms and outdoor areas provided Providing access to the community health center additional spaces for waiting and eased the pressure was the number one concern from all of the sites on the typically overcrowded waiting area. Positive interviewed and visited. The location of the building distractions found throughout the waiting spaces and needed to be within the neighborhood of the lobby/reception areas included audiovisual material residents served to reinforce access to care. Providing on a variety of devices (handheld devices, kiosks and enough parking for patients and visitors can televisions), artwork, educational materials, views enhance access to care. Many of the sites visited and to the outdoors, and TV programming as well as interviewed, due to an urban setting, did not have electronic monitors to inform patients about waiting nearly enough parking for their visitors. At many of time. The waiting areas, lobbies and reception areas the sites, improving access to care also meant either tended to be open and bring plenty of daylight into providing alternative transportation for patients or the spaces; many of the facilities have high-end being located on/near the bus route and train station. 14 | C alifornia H ealth C are F oundation finishes, bright colors, and natural wood accents to many facilities did not designate a play area but bolster community pride. incorporated elements of play throughout. Health information is communicated to patients Exam Room/Procedure Space not only through the provider-patient relationship Bringing services to the patient is becoming the new but through multiple venues such as resource model of care throughout many of the facilities. centers and Internet connections. Many facilities are At Southcentral Foundation’s Native Primary Care transitioning to electronic medical records (EMRs) to Clinic, for example, integrating the physician, nurse communicate health information between providers. case manager, behaviorist, and nutritionist’s care With advances in technology, providing care through within the exam room creates an opportunity to telemedicine will become more apparent. change the layout of the space; a chair, furnishings, and a medical supply cabinet but no exam table are Security and Privacy used to lower the power differential and continue the The location of some clinics makes security of staff process of building a relationship with the patient. and patients an issue. Designing a space to be secure Additionally, at a few sites, furniture modifications but accessible and welcoming is a challenge. At many within the exam rooms have been made to strengthen of the clinic locations, a security guard is on-site communication between the patient and provider. to provide a physical presence; other locations use Because of the variety of services provided, the exam cameras, monitoring systems, or keycard-access doors rooms need to be multi-purposed and age-specific. to facilitate the necessary separation of medical spaces Many of the clinics have standardized the provision from public spaces. of certain equipment and supplies in their exam Maintaining patient privacy is an issue rooms, but have not standardized the specific layout within waiting and lobby areas. Facilities have or size of that equipment. addressed privacy issues in a variety of ways such as architectural designs, furniture placement, the use of Ambient Experience, Information, acoustic-sensitive materials and fabric, and creating and Technology separate areas for discussion (e.g. designated quiet Color palettes featured within the various clinics areas and consult rooms). were dependent on the cultures of the communities served. The colors ranged from earth tones to bright Spatial Relationship colors. Many of the recently designed facilities When considering adjacencies of services, the current (within the past two years) featured wood finishes. staff and patient flow should be documented. In Providing access to nature whether it was through several of the clinic spaces, the exam rooms, medical window views, a roof-top garden, or an adjacent city assistant stations, and provider offices were organized park was deemed a priority. At Bolinas Community along concentric circles with the provider offices Health Center, the building is sited in such a way on the perimeter of the space and the exam rooms that every space within the facility has a view to within the interior. Designing for change through nature. Play areas within the lobby setting, waiting multi-purpose spaces is a common theme; many areas, and exam rooms added to the ambience; of the facilities are utilizing one space for differing functions (e.g. the mental health treatment room can Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 15 function as a consult space or an overflow waiting added value to the design process as well as created area). an opportunity to step outside of what is typically designed or thought. Staff Features Many of the individuals involved with the design Throughout the facilities interviewed and visited, process stated that hiring an architect with credible there was no shortage of unique staff features. experience in community clinic/health center Dedicated staff lounges, restrooms, kitchens, locker design was very important. While the trend is to rooms, and conference rooms were abundant in both pursue LEED certification, many of the facilities are the new designs for future facilities as well as in the utilizing architects familiar with sustainable choices, existing spaces. Many of the conference rooms were which allow the planning and design team to choose geared towards multi-purpose functioning not only environmentally-friendly materials, flooring, and as a training space for staff but as a place for media furniture if LEED certification is not feasible. Several events and educational discussions. Several facilities facilities have utilized the building project and have designed a work station for every provider and process to educate the community, solicit support, staff member to be equipped with a computer. and cater events around the services provided. Connection to Community Social responsibility is customary for community clinics/health centers as they provide services and programs and deliver care to all those in need. Many of the clinics interviewed and visited offered care not only within their clinics but in homes, schools, and traveling vans. Being located within the neighborhood of the residents served, the community clinic is an anchor for medical care and jobs. A common theme within all of the sites was the relationship developed with other entities or organizations to strengthen the programs offered. Building Process Many of the facilities interviewed and visited are currently planning a new or renovated space or have recently completed a significant project. Several facilities involved key stakeholders including patients in the community, board members, and other community leaders in the planning process. Educating the entire team about the building process through attending related conferences and visiting other community clinics and health centers 16 | C alifornia H ealth C are F oundation V. Design Recommendations. W hile there is a growing body of The “When to incorporate” column indicates the research on the impact of the design of ambulatory types of situations (new construction, renovation, care environments on outcomes, there are very or existing facility) in which the design strategy can few studies that specifically address issues around be cost-effectively incorporated into the physical safety-net clinic design. This table pulls together the environment. The “Cost” column reflects costs of design recommendations for safety-net clinics based incorporating this strategy relative to other strategies. on the findings from the literature review as well as A wide range of costs reflects the scale of changes best practice case studies. These recommendations and whether the strategy is to be incorporated in a are not meant as prescriptive guidelines; rather, it is new facility or in a renovation. The “Source” column recommended they be used as guiding considerations indicates the source for the design recommendation: during the design process. whether it came from the literature review or from the best practice case studies. Table 2. Design Recommendations, continued W h en to   incorporate Cost S o u rce N ew C onstruction L iterature review R enovation C ase stud y M oderate E x isting H igh L ow Access                 Ensure convenient physical access  x          x  x  x Make accessible along public transportation routes  x          x  x  x Locate clinic presence within neighborhood of residents served  x  x  x Utilize clear signage and wayfinding  x  x  x    x    x  x Mail hand-held maps for easier wayfinding  x  x  x  x        x Avoid highly symmetric facilities that influence wayfinding negatively  x          x   Provide bike racks and walking paths around and near clinic facilities  x  x  x  x  x  x Reinforce community commitment through the selection of interior aesthetics  x  x  x  x  x Utilize color coding and symbol signage to aid in wayfinding within the clinic  x  x  x  x  x Provide well-lit and secure entryways  x  x  x  x Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 17 Table 2. Design Recommendations, continued W h en to   incorporate Cost S o u rce New Construction Literature review Renovation Case study Moderate Existing High Low Waiting/Registration Areas                 Identify clear spatial boundaries for waiting areas  x  x      x    x Lighter finishes and wall-mounted lighting preferred  x  x    x        x Design physically attractive waiting areas  x  x      x      x Provide an environment that is clean, calm, and quiet  x  x  x    x    x  x Utilize electronic sign-in kiosks to speed up registration  x  x        x    x Provide children with safer hard toys within play areas (easier to disinfect)  x  x  x  x  x Use televisions as positive distractions  x  x  x  x      x  x Provide computers connected to Internet for browsing  x  x  x    x      x Provide age-appropriate positive distractions or waiting room entertainment/activities  x  x  x    x    x  x (e.g., pediatric clinic serves various age groups) Use posters, displays, newsletters — sometimes effective  x  x  x  x      x  x Design an open setting which can aid social interaction in some cases  x  x        x  x  x Ensure multiple areas for waiting (outside, inside, overflow)  x  x  x  x  x Provide information kiosks within lobby space  x  x  x  x Consider acoustic properties of materials found within waiting areas to aid in minimizing  x  x  x  x  x noise Provide a variety of lighting options (controlled, natural, skylights)  x  x  x  x  x Exam/Consulting                 Consider adjustable features for technological equipment to enable changing models of  x  x  x      x  x  x care (e.g., sharing on-screen information with patient) Use posters to effectively communicate information  x  x  x  x      x   Utilize non-educational reading or electronic media for pediatric clinics  x  x  x  x  x    x  x Enable patient-clinician communication through flexible layout of exam space  x  x  x  x Consider the furnishing in exam rooms to lower the power differential between provider  x  x  x  x  x  x and patient Maximize unused space within exam rooms (e.g. chamfered corners)  x  x  x  x  x Provide ample space for family within exam and procedure rooms  x  x  x  x  x Design exam rooms/procedure space to include multiple caregivers as a part of the  x  x  x  x  x caregiving process Standardize placement of equipment and supplies within treatment and exam room  x  x  x  x 18 | C alifornia H ealth C are F oundation Table 2. Design Recommendations, continued W h en to   incorporate Cost S o u rce New Construction Literature review Renovation Case study Moderate Existing High Low Procedures                 Enable audio-visual distractions — enabling technology needed for this  x  x        x  x   Ensure access to daylight  x  x      x  x    x Ensure access to window views of nature  x  x      x  x    x Provide strong acoustic ratings of dividing walls for informational/conversational privacy  x  x      x    x  x Consider sight angles into and out of rooms for visual privacy  x  x      x    x   Consider sight angles to computer screens from exterior of room for patient privacy  x  x      x      x Provide ample space for family within exam and procedure rooms  x  x      x  x  x Design exam rooms/procedure space to include multiple caregivers as a part of the  x  x  x  x  x care-giving process Standardize placement of equipment and supplies within treatment and exam room  x  x  x  x Discharge                 Consider separate entry/exit for mental health patients  x  x      x    x Staff Areas                 Include staff experiences and participation in programming process, especially as design  x  x      x    x  x responses to desired workflow patterns are planned Consider appropriate rates of illumination for tasks to be conducted accurately  x  x    x        x Consider layout and ergonomics that can make work patterns more efficient — for  x  x        x  x  x example, circular layout for pharmacy for dispensing medicines quickly and efficiently Consider adequacy of spaces for affiliated non-traditional staff  x  x  x  x Design furniture and fixed cabinetry for correct ergonomic solutions  x  x  x  x  x Provide a designated computer workstation for all staff  x  x  x  x  x Provide secure access for staff-only areas  x  x  x  x  x Operational Issues                 Consider impact of moving to electronic medical records on technology needs and space  x        x    x   needs (may need less square footage with EMRs — but may need more tech support) Accommodate new staff (e.g., counselors) in addition to traditional staff as models of  x  x  x    x    x  x care change Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 19 VI. Conclusion T his report summarizes the findings Consider improvements to the physical from a research project that included a review environment in conjunction with process of literature examining evidence-based design in redesign and operational changes in order for the ambulatory care clinics (ACCs), and best practice design changes to be effective. case studies of community health center designs. With new construction, pay attention to the This document provides a comprehensive set of location of the facility within the community or practice and design considerations for designing new communities served to promote ease of access for safety-net clinics and retrofitting existing facilities. community members. Some of these design strategies such as providing space for families within examination rooms are Create attractive, comfortable waiting areas that easier to incorporate within new construction or cater to the needs of the population(s) being during a significant renovation. However, there served. Provide different types of age-appropriate are several design modifications that can be done distractions in waiting areas including views easily in an existing facility at relatively low cost. to nature, computer terminals, safe toys, and Examples include improving the ambience of posters. waiting areas through furniture placement or a Consider how the design balances patient privacy new paint palette, or furnishing exam rooms to with needs for security and for staff and patient improve patient-physician interaction. These and safety. other design strategies, including cost estimates, are outlined in the Design Recommendations section Pay careful attention to the design of the above, including guidance on when they are best examination/procedure room. The design should incorporated within the building design. support interaction and communication between In addition to generating specific design patient and physician as well as accommodate recommendations, the literature review and case family as participants in care. Rooms should also studies provide insight into a wide range of issues be sized to accommodate multiple caregivers as involved in the design of safety-net clinics. Decision part of the caregiving team. makers should consider the following key strategies With the increasing focus on providing and practices while designing new safety-net clinics patient-centered care in outpatient environments, or retrofitting old ones: it is becoming more essential to create physical Involve staff in the design process. Their input is environments that truly support such a model of valuable and their involvement in the process will care. Best practices in terms of safety-net clinic design result in greater buy-in and success in achieving are evolving as the role and focus of safety-net clinics intended outcomes. themselves evolve. 20 | C alifornia H ealth C are F oundation Appendix: Case Studies Sites Visited Bolinas Community Health Center Bolinas, Marin County, California La Clinica de la Raza Fruitvale Village, Alameda County, California La Maestra Community Health Clinic San Diego (City Heights), California Lifelong Medical Care Over 60 Health Center Berkeley, California Sites Interviewed Parkland Health Irving Health Center Irving, Texas Thundermist Health Center Woonsocket, Rhode Island Clinica Sierra Vista The Central Bakersfield Community Health Center Bakersfield, California Golden Valley Health Centers Merced (Merced Suites), California Southcentral Foundation’s Anchorage Native Primary Care Clinic Alaska Native Medical Center Anchorage, Alaska Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 21 Endnotes 1. The Lewin Group. 2006. Evaluation of the California 9. Moreno, L. 2005. “Electronic Health Records: HealthCare Foundation’s Ambulatory Care Redesign Synthesizing Recent Evidence and Current Policy.” Issue Collaborative. Report for the California HealthCare brief. Princeton, NJ: Mathematica Policy Research, Inc. Foundation (www.chcf.org/documents/policy/ 10. Ulrich, R. S., Quan, X., Zimring, C., Joseph, A., and evaluationofambulatorycareredesign.pdf). Choudhary, R. 2004. The Role of the Physical Environment 2. Starfield, B. and Shi, L. 2004. “The Medical Home, in the Hospital of the 21st Century: A Once-in-a-Lifetime Access to Care, and Insurance: A Review of Evidence.” Opportunity. Report to the Center for Health Design Pediatrics. 113 (5): 1493 –1498. (www.healthdesign.org/research/reports/pdfs/role_ physical_env.pdf). 3. Taylor, J. 2004. “The Fundamentals of Community Health Centers.” A National Health Policy Forum Paper. 11. O’Malley, A. S., Forrest C. B. and O’Malley P. G. 2000. Washington D.C. National Health Policy Forum. “Low-Income Women’s Priorities for Primary Care.” The Journal of Family Practice. 49 (2): 141–146. 4. Weiss, E., Haslanger, K., and Cantor, J. C. 2001. “Accessibility of Primary Care Services in Safety-Net 12. Rave, N., Geyer, M., Reeder, B., Ernst, J., Goldberg, Clinics in New York City.” American Journal of Public L., and Barnard, C. 2003. “Radical Systems Change: Health. 91 (8): 1240 –1245. Innovative Strategies to Improve Patient Satisfaction.” Journal of Ambulatory Care Management. 26 (2): 5. Saviano, E. C., and Powers, M. 2005. California’s 159 –174. Safety-Net Clinics: A Primer. Report for the California HealthCare Foundation (www.chcf.org/documents/ 13. Baskaya, A., Wilson, C., and Özcan, Y. Z. 2004. chronicdisease/safetynetclinicprimer.pdf). “Wayfinding in an Unfamiliar Environment: Different Spatial Settings of Two Polyclinics.” Environment and 6. Healthcare Financial Management Association. Behavior. 36 (6): 839 – 867. 2008. Financing the Future II: Report 4 — Healthcare Construction Trends and Capital Implications. In 14. Baggri, H. S. and Jenkins, D. 2007. “A Survey to Assess partnership with GE Healthcare Financial Services the Preferences of Patients with Diabetes for the Time (www.hfma.org/nr/rdonlyres/50B6AC7F-4B08-4B22- and Location of their Outpatient Appointments.” 9E9F-D8CD1D071BB3/0/400601FNFIIIrpt4.pdf). Practical Diabetes International 24 (7): 366 – 370. 7. Fowler, E., MacRae, S., Stern, A., Harrison, T., Gerteis, 15. Baskaya et al., 2004. M., Walker, J., Edgman-Levitan, S., Ruga, W. 1999. 16. Dey, P., Bundred, N., Gibbs, A., et al., 2002. “Costs “The Built Environment as a Component of Quality and Benefits of a One-Stop Clinic Compared with a Care: Understanding and Including the Patient’s Dedicated Breast Clinic: Randomized Controlled Trial.” Perspective.” The Joint Commission Journal on Quality BMJ 324: 507 – 511. Improvement. 25 (7): 352 – 362. 17. Akalin-Baskaya, A. and Yildrim, K. 2006. “Design of 8. American College of Physicians. 2006. “The Advanced Circulation Axes in Densely Used Polyclinic Waiting Medical Home: A Patient-Centered, Physician-Guided Halls.” Building and Environment. 42: 1743 –1751. Model of Health Care.” Policy Monograph (www.hhs.gov/healthit/ahic/materials/meeting03/cc/ 18. Lindberg, L. and Holmes, S. 2007. Medical practice acp_initiative.pdf). top improvers — A client resource of innovation and best practices. South Bend, IN: Press Ganey Associates, Inc. 22 | C alifornia H ealth C are F oundation 19. Tsai, C., Wang, M., Liao, W., Lu, J., Sun, P., Lin, B. Y., 30. Philips, S. 2007. “Assessing Patient Flow in an Breen, G. 2007. “Hospital Outpatient Perceptions of Ambulatory Oncology Setting.” Oncology Nursing Forum. the Physical Environment of Waiting Areas: The Role 34 (2): 505. of Patient Characteristics on Atmospherics in One 31. Gillian, S. S., Blanken, S. E., Greiner, K. A., and Academic Medical Center.” BMC Health Services Research. Chumley, H. S. 2008. “Visual Prompt Poster for 7: 198 (www.biomedcentral.com/content/pdf/1472- Promoting Patient-Physician Conversations on 6963-7-198.pdf). Weight Loss.” Annals of Family Medicine Jan/Feb 2008 20. Becker, F. and Douglass, S. J. 2008. “The Ecology of the Supplement, Vol. 6, pS33 – S36. Patient Visit: Physical Attractiveness, Waiting Times, and 32. Tivorsak et al., 2004. Perceived Quality of Care.” Journal of Ambulatory Care Management. 31 (2): 128 –141, April/June 2008. 33. Deshefy-Longhi, T., Dixon, J. K., Olsen, D., and Grey, M. 2004. “Privacy and Confidentiality Issues in Primary 21. Leather, P., Beale, D., Santos, A., Watts, J. and Lee, Care: Views of advanced practice nurses and their L. 2003. “Outcomes of Environmental Appraisal of patients.” Nursing Ethics. 11 (4): 378 – 393. Different Hospital Waiting Areas.” Environment and Behavior. 35 (6): 842 – 869. 34. Walworth, D.D. 2005. “Procedural-Support Music Therapy in the Healthcare Setting: A Cost-Effectiveness 22. Tsai et al., 2007. Analysis.” Journal of Pediatric Nursing. 20 (4): 276 – 284. 23. Rave et al., 2003. 35. Diette, G. B., Lechtzin, N., Haponik, E., Devrotes, 24. Cheng, C. M. 2004. “Simple Additions to the Pharmacy A., Rubin, R. H. 2003. “Distraction Therapy with Waiting Area may Increase Patient Satisfaction.” Journal Nature Sights and Sounds Reduces Pain During Flexible of the American Pharmacists Association. 44 (5): 630 – 632. Bronchoscopy.” Chest: The Cardiopulmonary and Critical Care Journal. 123 (3): 941– 948. 25. Tivorsak, T. L., Britto, M. T., Klostermann, B. K., Nebrig, D. M., Slap, G. B. 2004. “Are Pediatric Practice 36. Lee, D. W. H., Chan, A.C.W., Wong, S.K.H., Fung, Settings Adolescent-Friendly? An Exploration of Attitudes T.M.K., Li, A.C.N., Chan, S.K.C., Mui, L. M., and Preferences.” Clinical Pediatrics. 43 (1): 55 – 61. Ng, E.K.W., and Chung, S.C.S. 2004. “Can Visual Distraction Decrease the Dose of Patient-Controlled 26. Merriman, E., Corwin, P. and Ikram, R. 2002. “Toys Sedation Required During Colonoscopy? A Prospective Are a Potential Source of Cross-Infection in General Randomized Controlled Trial.” Endoscopy. 36: 197 – 201. Practitioners’ Waiting Rooms.” British Journal of General Practice. 52: 138 – 140. 37. Schneider, S. M., Prince-Paul, M., Allen, M. J., Silverman, P., and Talaba, D. 2004. “Virtual Reality 27. Pritchett, J. K. and Buckner, E. B. 2004. “Parental as a Distraction Intervention for Women Receiving Views of the Social Environment of an Outpatient Bone Chemotherapy.” Oncology Nursing Forum. 31 (1): 81– 88. Marrow Transplant Clinic.” Journal of Pediatric Oncology Nursing. 21 (5): 264 – 270. 38. Melamed, Y., Szor, H., and Bernstein, E. 2001. “The Loneliness of the Therapist in the Public Outpatient 28. Cohn, E. S. 2001. “From waiting to relating: parents’ Clinic.” Journal of Contemporary Psychotherapy. 31 (2): experiences in the waiting room of an occupational 103 – 112. therapy clinic.” American Journal of Occupational Therapy. 55 (2): 167–174. 39. Racine, A. D. and Davidson, A. G. 2002. “Use of a Time-Flow Study to Improve Patient Waiting Times at 29. Frankel, R., Altschuler, A., George, S., Kinsman, J., an Inner-City Academic Pediatric Practice.” Archives of Jimison, H., Robertson, N. R., and Hsu, J. 2005. Pediatric and Adolescent Medicine. 156 (12): 1203 – 1209. “Effects of Exam-Room Computing on Clinician-Patient Communication: A Longitudinal Qualitative Study.” Journal of General Internal Medicine 20(8): 677 – 682. Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 23 40. Wang, S. J., Blackford Middleton, Prosser, L. A., Bardon, 61. Tivorsak et al., 2004. C. G., Spurr. C., Carchidi, P. J., Kittler, A. F., Goldszer, 62. Gillian et al., 2008. R. C., Fairchild, D. G., Sussman, A. J., Kuperman, G. J., and Bates, D. W. 2003. “A Cost-Benefit Analysis 63. Rave et al., 2003. of Electronic Medical Records in Primary Care.” The 64. Lee et al., 2004. American Journal of Medicine. 114: 397 – 403. 65. Walworth, 2005. 41. Wang et al., 2003. 66. Loewy, J., Hallan C., Friedman E., and Martinez C. 42. American College of Physicians. 2003. “The Paperless 2005. “Sleep/Sedation in Children Undergoing EEG Medical Office: Digital Technology’s Potential for the Testing: A Comparison of Chloral Hydrate and Music Internist.” Philadelphia: American College of Physicians; Therapy.” Journal of PeriAnesthesia Nursing. 20 (5): Discussion Paper. (Available from American College 323 – 331. of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.) 67. Gershon, J., Zimand, E., Lemos, R., Rothbaum, B. O., and Hodges, L. 2003. “Use of Virtual Reality as 43. O’Malley et al., 2000. a Distractor for Painful Procedures in a Patient with 44. Bean-Mayberry, B. A., Chang, C. H., McNeil, M. A., Pediatric Cancer: A Case Study.” Cyberpsychology & Whittle, J., Hayes, P. M., Scholle, S. H. 2003. “Patient Behavior. 6 (6): 657– 661. Satisfaction in Women’s Clinics Versus Traditional 68. Schneider et al., 2004. Primary Care Clinics in the Veterans Administration.” Journal of General Internal Medicine. 18 (3): 175 – 181. 69. Diette et al., 2003. 45. Rave et al., 2003. 70. Baggri and Jenkins, 2007. 46. Dey et al., 2002. 71. Tivorsak et al., 2004. 47. Baskaya et al., 2004. 72. Pritchett and Buckner, 2004. 48. Akalin-Baskaya and Yildrim, 2006. 73. Merriman et al., 2002. 49. Steelcase 2006. “Case Study: Mayo Clinic.” SPARC 74. Deshefy-Longhi et al., 2004. Innovation Program. 75. Deshefy-Longhi et al., 2004. 50. Tsai et al., 2007. 76. Rouf, E., Chumley, H. S., and Dobbie, A. L. 2008. 51. Rave et al., 2003. “Electronic Health Records in Outpatient Clinics: Perspectives of Third-Year Medical Students.” BMC 52. Cheng, 2004. Medical Education. 8: 13 doi:10.1186/1472-6920-8-13 53. Rave et al., 2003. (www.biomedcentral.com/1472-6920/8/13). 54. Lindberg and Holmes, 2007. 77. Frankel et al., 2005. 55. Leather et al., 2003. 78. Lin et al., 1988. 56. Becker and Douglass, 2008. 79. Getrich, C., Heying, S., Willging, C., and Waitzkin, H. 2007. “An Ethnography of Clinic ‘Noise’ in a 57. Pritchett and Buckner, 2004. Community-Based, Promotora-Centered Mental Health 58. Tsai et al., 2007. Intervention.” Social Science & Medicine. 65: 319 – 330. 59. Merriman et al., 2002. 80. Kildea-Pahl, D., Baltimore, J., and Kosiara, B. 2001. “Outpatient Surgery Care Unit Work Process Redesign.” 60. Lindberg and Holmes, 2007. Journal of PeriAnesthesia Nursing, 16 (2): 70 – 81. 24 | C alifornia H ealth C are F oundation 81. Kildea-Pahl et al., 2001. 82. Getrich et al., 2007. 83. Kildea-Pahl et al., 2001. 84. Racine and Davidson, 2002. 85. Wang et al., 2003. 86. Rave et al., 2003. 87. Wang et al., 2003. 88. Dey et al., 2002. Improving the Patient Experience: Best Practices for Safety-Net Clinic Redesign | 25 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org