The move to outpatient-based care has prompted the Facility Guidelines Institute to release a stand-alone Guidelines for Design and Construction of Outpatient Facilities reference for 2018
As the U.S. health care field looks for ways to improve efficiency and patient satisfaction while reducing costs, the move from hospital-based services to those provided in outpatient facilities continues apace. Surgeries once limited to hospital settings, such as joint replacements, are now offered in ambulatory surgery centers; some procedures formerly limited to procedure rooms are now conducted in exam rooms; and some exams are now performed via telemedicine.
These trends not only impact the delivery of care, but also the design of health care facilities.
To support this evolution in practice, the Facility Guidelines Institute (FGI) has separated requirements for hospitals from those for outpatient facilities for the 2018 edition of its minimum standards Guidelines, expanding the series to three documents: Guidelines for Design and Construction of Hospitals; Guidelines for Design and Construction of Outpatient Facilities; and Guidelines for Design and Construction of Residential Health, Care, and Support Facilities.
The primary goal of developing the new Outpatient Guidelines was to make it flexible enough to address the expanding variety of outpatient facilities being designed today.
The facility types included range from small clinics, doctors’ offices and tenant improvements in a larger building to medical office buildings (MOBs) that house multiple clinical services and large freestanding imaging or surgery centers. As well, the Outpatient Document Group, a subcommittee of the Health Guidelines Revision Committee (HGRC), added text to help users of the document apply its requirements to projects of all sizes and complexities.
Two application approaches
Today’s outpatient facility design projects are often at the vanguard of practice, imagining new facility types or combining diverse health care services into one building. Therefore, designers may not find a chapter in the Guidelines that neatly aligns with their project. To address such situations, the Outpatient Document Group adapted a method used by authorities having jurisdiction (AHJs) in the field. The result is two methods for applying the Guidelines — Approach 1 and Approach 2 — described at the beginning of Chapter 2.1, Common Elements for Outpatient Facilities.
Approach 1 is for projects meeting the scope of services “comprehensively described” in one of the specific facility-type chapters in the Guidelines. Approach 2 is for projects not specifically described in a facility chapter, but that include health care services covered in one or more chapters (the common elements chapter and/or one or more of the facility chapters). A project suited to this approach would be an MOB that houses an ambulatory surgery center, imaging services and physicians’ offices (requirements in the outpatient surgery, common elements, and general and specialty medical services facility chapters).
The FGI's stand-alone reference for outpatient facilities
In the section presenting the two approaches, appendix language indicates that careful development of a functional program to establish physical environment requirements is critical for successful delivery of a project using Approach 2. The project team begins by identifying the clinical and support services to be included, then identifies the sections of the Guidelines that have requirements for the relevant facilities. In states where the AHJ requires it, the identified requirements are presented to the AHJ for review and approval before the design is completed.
Expanded common elements
The new Outpatient Guidelines features more requirements in the common elements chapter than previous editions did. This change recognizes that these spaces may appear in multiple outpatient facility types, and placing them in the common elements chapter makes it easier to cross-reference them from specific facility chapters. It also supports the Approach 1 and 2 concept for applying Guidelines requirements to outpatient facility projects.
- Accommodations for care of patients of size. The Guidelines first included design standards to accommodate “bariatric patients” in the 2010 edition, but the HGRC wasn’t happy with the results and subsequently removed much of this material. For the 2018 edition, FGI convened a bariatric accommodations topic group, inviting HGRC members, experts in patient handling and interested Guidelines users to develop proposals to address this important issue. One result is replacement of the term “bariatric patient” with “patient of size” to include patients who do not meet the clinical definition of obese, but still require expanded clearances and/or expanded-capacity lifts. Determining a facility’s need to accommodate patients of size is required during the planning phase, including projecting weight capacities for the population to be served and the number of patient care spaces and expanded-capacity lifts required. Minimum design requirements for safe delivery of care to patients of size, based on mock-ups of patient care spaces at a workshop hosted by an equipment vendor, were also added. These include clearances for rooms in which overhead or floor-based lifts are used and door openings along the path of travel.
- Clinical service rooms. Because many outpatient facility types may include examination rooms, procedure rooms and operating rooms (ORs), requirements for these clinical spaces were placed in the common elements chapter. A new table summarizes the design requirements for these rooms to help Guidelines users determine whether a clinical space must meet the requirements for a procedure room or an OR. Options are provided for procedure rooms and ORs to make it easier to incorporate them in various outpatient facility types. The minimum clear floor area for a procedure room has been reduced from 150 to 130 square feet. The minimum clear floor area for an operating room is 255 square feet as calculated using the required clearances. Rooms in which an anesthesia machine and cart will be used require more space, and fixed encroachments can be accommodated in defined instances.
- Accommodations for telemedicine services. The use of telemedicine is rapidly expanding in the United States, particularly in rural areas where specialty medical services can be nonexistent. To support this growing service, minimal design requirements were added for spaces where clinical telemedicine services are provided. Use of bays, cubicles or rooms is permitted, and space requirements depend on the equipment and persons being accommodated. Considerations for privacy, lighting, surfaces, acoustics and facility identification are included in the appendix.
- Imaging services spaces. Design requirements for imaging facilities are included in the common elements chapter and referenced from facility chapters that may include imaging services. The imaging text was restructured using a new classification system to streamline requirements and help designers to determine which imaging classes apply to their projects. Space requirements depend on clearances around the equipment being used. General imaging room requirements are provided and amended with details that apply to specific imaging modalities. This approach allows imaging room design to adapt more easily to new technologies and changes in equipment.
- Pre- and post-procedure patient care areas. The requirements for pre- and post-procedure patient care areas were revised to allow health care organizations to provide either separate pre-procedure and recovery patient care areas or to combine them — including Phase I and Phase II recovery areas — into one space. When a combined area is provided, it must meet the most restrictive design requirements for the space types included. Facilities still may choose to separate services into two or three areas, but the change offers greater flexibility in the provision of care. Use of procedure and operating rooms for pre-procedure and recovery is also permitted.
- Waiting areas or rooms. The 2014 Guidelines had limited requirements for waiting spaces in outpatient facilities, with specific seating ratios in only two chapters. A task group of the Outpatient Document Group looked into changing these requirements to avoid design of facilities with insufficient waiting space. But, after much consideration, the requirements for waiting spaces were limited to determining the needed space for waiting during the planning stage and making the waiting area visible from a staff area. Ratios for seats in a waiting area were moved to the appendix and supplemented with recommendations for ratios in nearly all the specific facility types in the document.
- Patient support facilities. Expanded laboratory, new pharmacy and revised sterile processing facility requirements have been added to the linen services requirements. These requirements only apply when referenced from a facility chapter or identified as relevant for projects using Approach 2. Of particular note is the updated sterile processing section. In the 2014 Guidelines, a one-room sterile processing facility was the minimum requirement. For the 2018 edition, the HGRC reconsidered this requirement and, considering the importance of maintaining a dirty-to-clean workflow, determined the minimum requirement for sterile processing spaces is a two-room sterile processing facility with a decontamination room and a clean workroom. A one-room sterile processing facility is permitted as an exception for facilities where small countertop sterilizers are used for a limited workflow.
- HVAC systems. The breadth of facility types in the Outpatient Guidelines generated considerable discussion about appropriate HVAC systems. In the end, the outpatient facility types fall into three categories: those that must comply with American National Standards Institute/ASHRAE/American Society for Healthcare Engineering Standard 170, Ventilation of Health Care Facilities (surgery and endoscopy facilities); those with certain room types that must meet requirements in Standard 170 (certain imaging facilities, infusion centers and renal dialysis centers); and those that follow state and local building code requirements (the rest of the chapters). Procedure and operating rooms also must meet the requirements in Standard 170. This arrangement allows flexibility in the design of outpatient facility ventilation systems, but still supports sound infection prevention practices in critical areas.
Specific facility types
Finally, the Outpatient Guidelines also has some changes for specific outpatient facility types. These include:
- Urgent care center. Clinical space requirements were revised for flexibility and now include both single-patient and multiple-patient exam rooms. As well, the urgent care procedure room was changed to a treatment room, reducing ventilation and other design requirements. For triage, a dedicated space, patient care station or consultation room may be used.
- Freestanding emergency facility. In the 2018 edition, this chapter appears in both the Hospital and the Outpatient Guidelines. The cross-references to the emergency services section of the general hospital chapter in the 2014 edition were converted to written requirements for the outpatient document.
- Endoscopy facility. The minimum clear floor area for the endoscopy procedure room was reduced from 200 to 180 square feet. Endoscope processing room requirements were updated to reflect the dirty-to-clean workflow required for sterile processing facilities.
- Outpatient psychiatric facility. Space requirements were added for consultation rooms, group rooms and observation rooms. Requirements for optional exam, seclusion and quiet rooms were also added. In addition, where the need is indicated by the behavioral and mental health risk assessment, “space for a clear path of escape for staff” and a “staff assist device to communicate with [others]” are required, although the “staff assist device” is required for all consultation and group rooms.
- Mobile/transportable medical unit. A guiding principle of the HGRC is that physical design requirements for specific medical services should be the same regardless of where those services are provided. To support that principle, the chapter on mobile/transportable medical units was completely revised for the 2018 edition based on the new imaging classification system and clarified requirements for examination/treatment, procedure and operating rooms. This chapter also appears in the 2018 Hospital Guidelines document.
Visit the FGI website to learn more about the 2018 FGI Guidelines documents or to purchase a copy.
Pamela James Blumgart is managing editor at the Facility Guidelines Institute. She can be reached at firstname.lastname@example.org.