The type of space that is required depends on what type of office or clinical space is being built.

“Turning a retail space into a primary care office is not particularly complicated in terms of remodeling,” says Dallam. “But the moment you start providing imaging, the remodels get more complicated. You need to consider shielding, power requirements, and hazardous materials from contrasts used. There’s also the weight of the equipment to consider.”

“The existing infrastructure of a retail facility may not work,” agrees Karen Stephens, project manager at Architects Alaska. “You need to consider several factors, such as floor-to-floor height, HVAC requirements, and, if the office is located on a building’s upper level, the fact that you might need to reinforce the floor to accommodate really heavy equipment like a floor-mounted CT scanner.”

“You need to protect what’s above and below, which may require radiation screening,” adds Kathleen Benoit, project manager at Architects Alaska. “And you also have to take into consideration the needs of the medical equipment itself; for example, an MRI can be affected by car traffic or by elevators, so it’s typical to put in lead-lined walls.”

Mixed-use buildings are also more challenging for designers, who need to create occupancy separation through the use of firewalls. They must also consider what type of medical facilities are allowed in certain types of buildings—a wood-framed building, for example, may not be appropriate to house certain types of medical equipment or procedures.

“If you’re working in a critical access facility, like a hospital, the facility has to stay open for emergencies, so it’s required to be built to a higher code and with a higher level of building materials,” says Benoit. “It needs to be able to withstand fires and earthquakes and still provide services to the community.”

“HIPAA does not dictate the need for separate rooms to keep information private, but staff in reception areas have to be very careful about how much information is said out loud,” adds Benoit. “Privacy is tricky, which is why we often design consultation rooms where people can go to talk about their medications, financial issues, and more.”

Patient flow is also a consideration, especially in ambulatory surgical centers where patients will be leaving after medical procedures. “People don’t always look or feel great after surgery, so you want to provide a way for them to leave discreetly,” says Stephens.

When remodeling a space, it’s important to try to keep disruptions to a minimum, especially in a mixed-use facility or within an already established healthcare facility that is treating patients. Unfortunately, this can add to construction costs.

“When the whole building can be gutted in one phase, it’s much easier. When you’re remodeling just a section of an existing space, you have to be extremely careful not to disrupt the portion of the building that is occupied,” says Benoit. “When you have to do things in phases to keep the facility open and operational, costs and time go up. You have to weigh the benefits of keeping the building open with the increased cost.”

While there are many factors to take into consideration when creating a healthcare space, one that is beginning to receive more attention is the need to holistically address the physical, mental, and social wellbeing of patients, staff, and community alike.

“Southcentral Foundation has become a national leader in reconceiving how care is provided, particularly primary care,” says Dallam. “When we first started working with them some thirty years ago, they raised the question: ‘How do we help people who want to use our resources to live a better life?’ They were not looking at healthcare as a transaction or as episodic; they wanted to find ways to help improve population health by changing the way that people think of it.”

Southcentral began by establishing a longitudinal, relationship-based care model that has evolved over time.

“They started simply by saying that if you call by 4 p.m. and can be at the office by 4:30, you will be seen by a care team,” says Dallam. “When Southcentral made that commitment, emergency room use dropped precipitously. When people are confident that they will be seen by their care provider in an outpatient setting almost immediately, instead of waiting for weeks for an appointment and then giving up and going to the emergency room [ER], it makes a big difference.”

Dallam adds that not only is the ER the most expensive way to get care but it is also the main route for inpatient bed utilization. In addition to reducing ER use by 50 percent, this innovation also reduced patient room utilization. Customer and staff satisfaction rates top 90 percent.

Family groups are seen by the same care team as a way to deal with social health issues. “If you treat a 16-year-old boy for obesity, chances are that treatment will not stick,” says Dallam. “But if you work with the whole family, you can begin to understand the root cause instead of just the symptoms.”

From a space perspective, the team approach required that Southcentral clinics be designed in a different way. It was a collaborative effort with NBBJ acting as the project’s architectural designers, Neeser Construction as the design-build team lead, and KPB Architects as the project architect. Southcentral’s Primary Care Center I was designed in 2002 and PCC II in 2010.

“When we were considering exam rooms, we asked how many client visits required disrobing, and the answer was only 40 percent; that’s where the innovation of the talking room came in,” says Dallam. “A lot of interactions are simple verbal exchanges, so there’s no need to feel anxiety walking into a room and seeing an exam table. While it was initially an experiment, it changed the orientation between providers and the people receiving care because they were no longer sitting separately.”

The teams, which include a primary care physician, nurse, case manager, one to two medical assistants, and an administrator, share a space that is divided by glass partitions from the other teams. Space was also created so that adjunct health professionals, such as behavioral, pharmacological, and nutrition experts, could come in and join the teams.

“We call it max packing—bringing all the resources to the person in one visit—which saves time and money, is more convenient, and allows the healthcare team to solve problems more completely,” says Dallam.

In addition to changing the way that healthcare spaces are designed, NBBJ worked to change attitudes as well. Words like “patient” and “compliant” have been shelved since they imply that people are passive bystanders in their own health journey. And some providers needed to be educated about the benefits of an open-plan layout that no longer included their own private spaces.

“One of the biggest issues we faced concerned the sanctity of the private office; physicians thought that they needed their own offices, but when you look at medical institutions, these spaces are empty most of the day,” says Dallam, adding that they also keep the doctors insulated.

“We had to work through the social process and talk to doctors about how the team format was ideal for helping them leverage their time better while keeping abreast of what was going on,” he continues.

Dallam adds that the new generation of medical professionals is more amenable to the team orientation and that medical administrators are also seeing the benefits of this type of approach.

NBBJ is currently in the process of working to understand another issue that is extremely important to healthcare—staff burnout.

“Emotional and mental fatigue are a major issue, so we’re working with a brain specialist to understand the science behind it so we can actively design environments to provide a counterbalance,” says Dallam. “If we continue to burn out the people who are providing care, we have no care system left. Our commitment is not just to patient health, but to everyone’s health.”