Putting Design into Practice

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RACGP

Western Australian general practitioner Dr Shiong Tan is thinking about his practice: not just the kind of care he provides, but also the brick and mortar surroundings in which he provides it. Dr Tan’s practice has outgrown its original architecture. The mix of acute and chronic care patients he and his colleagues treat at their group practice in Perth has changed in the ten years since the practice was originally built. “It worked well for a while,” says Tan, “but we realised that to run both kinds of care we need an efficient patient flow. We can’t do it the way the practice is physically structured, and we don’t have the luxury of dispensing with the building and starting again.”
Dr Tan and his colleagues are planning to add an extra 220 square metres to the practice – but Tan knows that extra space alone won’t solve the problem of keeping his flow of quick visit, acute care patients distinct from his longer visit, chronic care patients. More important is how the space is actually used to triage and accommodate waiting patients, to have them seen by practice nurses and doctors, and to get them to the billing desk and home again.
“We made the decision to carve out a different flow for our acute and chronic care patients so we could give uninterrupted care in a timely fashion.”

For Dr Tan and his colleagues, this means thinking about how the design of their practice can best serve the health care they provide, instead of providing health care within the constraints of their working environment. Evolving workplaces It’s this kind of thinking that has helped produce a gradual evolution in workplace design. While conventional office buildings continue to hem staff into stale grey cubicle honeycombs, the dotcom era has seen a flowering of more innovative and adventurous working environments.

Employees of the internet goliath Google, for example, hold meetings on couches, enjoy twice weekly roller hockey matches in the car park, and have access to video games, ping pong tables and even a baby grand piano. And at the space age London offices of energy drink manufacturer Red Bull, staff and visitors have the choice of conveying themselves between floors by means of a retrofuturistic slippery slide.

These vibrant workplaces reflect the nature of the companies behind them. But general practice – diverse, innovative and community-centred – often operates in environments that are not only unreflective of the profession, but are demonstrably unsuited to the services that GPs provide. Consider the classic converted period home: rich in character but lacking in practicality, with narrow central corridors inviting bottlenecks and restricting communication between GPs and practice staff.

At the other extreme, the modern converted office or shopfront has the potential to be sterile in the most undesirable sense of the word. In the pursuit of excellence Practice design is a real issue.

“We know that a pleasant workplace improves the wellbeing of our patients and our teams,” says RACGP President Dr Vasantha Preetham. “We know that the care we provide can be enhanced by investing in the environment in which we work – be it a reliable stethoscope or a whole practice.”

General practitioners aren’t blind to this– far from it. Each week, the RACGP receives enquiries from GPs seeking realistic guidance on how to design or redesign their practices. This is more than an exercise in aesthetics: it’s about solving very real problems of space and environment, so that GPs aren’t faced with the irony of practising the healing art in a sick building. Seeking guidance In 1984, the RACGP produced a handbook for GPs entitled The design of doctors’ surgeries. The handbook offered practical advice for correcting common design faults such as poor climate and sound control, lack of parking space and suitable entrances for people with restricted mobility, inadequate signposting, dysfunctional layout, ill fitting and undersized consulting rooms, and inadequate space for staff facilities. These issues are as important today as they were in 1984 – but advances in general practice, architecture and technology have highlighted the need for a new handbook to meet the design, workplace and environmental challenges of the twenty-first century. The result is an evidence based handbook that GPs will be able to use to solve design issues in their existing practices and to communicate their desires and intentions to an architect, designer or tradesperson.

Flexible designs for a diverse profession
The first step in developing a new handbook for GPs was to define excellence in practice design. Work began in July 2007, when the RACGP formed a partnership with RMIT Architecture – a meeting of industry leaders in health and architecture to marry ‘best practice’ design with the needs of GPs, practice staff and other health care professionals. The result of this partnership – involving close collaboration with RMIT Architecture lecturers Graham Crist and Brendan Jones – is a set of principles that the RACGP and RMIT believe underpin design excellence (see above). Recognising the diversity of general practice, for example, the design principles in the updated handbook are applicable to both large and small practices, and take into account the expanded range of services GPs offer. The handbook also offers advice on adapting design ideas across the range of environments in which general practice operates, from the tropical north to southern snowfields, and from remote outback locations to the inner city surgery. Flexibility extends to how space is used within the practice. Not all practices will be able to invest in building teaching rooms, meeting rooms, student rooms, allied health rooms and dedicated spaces for learning and creativity. The new handbook shows GPs how they can design spaces that are flexible enough to suit multiple purposes.

Communication and community
Primary health care typically begins with a conversation between patient and doctor, and colour and light are essential in creating a space in which patients feel comfortable enough to communicate effectively with GPs and practice staff. Gordon Young, one of the authors of the original The design of doctors’ surgeries, suggested that a ‘poor standard of decor’ was perhaps a greater problem in general practice design than any functional deficiency. “Patients don’t want to go to a corporate looking medical centre,” says Dr Tan. “They want to feel at home.” It’s important not just for the patient to feel at home, but for the practice to appear at home in its surroundings. A design that integrates a practice with its environment reinforces the idea that general practice is at the heart of the community. RMIT Architecture student Yongpeng Sheng’s concept for a practice located on a busy inner city road is a blend of the manmade and natural worlds. The facade is latticed with long, thin windows running the length and height of the building, echoing the trunks and branches of the tall gum trees located on the site. The result is that the trees seem to cast shadows that penetrate into the building itself, opening the practice to the neighbourhood while preserving the intimacy and privacy of the consulting space.

Solving problems
Not all GPs will be seeking to redesign their practices so dramatically. The purpose of the new handbook is to help GPs take advantage of evidence based design to solve problems, and to explore creative but cost effective possibilities for their practices – whether they’re renovating an individual consulting room or building an entire medical centre. “We need dialogue between general practice and the architecture profession,” says Dr David Oberklaid, whose South Melbourne practice was one of a number of clinics visited by RMIT Architecture students. “I think all of us would welcome ideas on how to better design and improve our practices. This is a first step, and we need to continue the dialogue.”

Meanwhile, Dr Tan and his colleagues have been working with an architect to solve some of their constraint issues and to explore ways of separating their acute and chronic care patient flows. One of the ideas that has sprung from this collaboration is the idea of installing half a dozen patient assessment ‘pods’ fitted with biometric instruments and data connections: an alternative to the traditional assessment area and a smarter use of the available space. “In systematic chronic disease recall care you don’t need a bed for the patient,” says Tan. “Instead, the patient can have their biometrics measured by the practice nurse in one of these pods and then move straight to see the doctor, where they can spend time specifically discussing long term issues.” The updated design guide for general practice will be published in May.