Squeezed for Space?
Even if you can't relocate, remodel or expand, you can make changes to alleviate the crunch.
By Richard C. Haines, Jr.

ILLUSTRATION: PHIL HOWE

As you consider the adequacy of your practice space, remind yourself why you have it to begin with. It may be a necessary evil, but it's necessary. In fact, it's as important a practice tool as any you have. It governs your production. It governs how effectively your staff can perform on your behalf as well as your patients'. It governs the impression your patients form about your practice.

But, if your operation is cramped in your current office space, and you're not able to move, what can you do?

Steps you can take

First, you need to understand that in your office you have three types of space:

• revenue generating space, such as refraction lanes (You've got two types of revenue generating space: those used by the doctor and those used by staff.) You must create adequate revenue generating space; without it, there's not much reason to proceed.
• necessary overhead support space, such as the waiting room
• unnecessary overhead space, such as an exercise room.

Here are some suggestions for solving problems related to each type of space:

Physician revenue generating space. You must have sufficient refraction lanes so you and your staff can see your patients at your optimal rate. If you're tight for space:

Staff revenue generating space. Generally, I recommend that practices have at least one staff diagnostic space for each staff member performing diagnostic tests. This allows them to do the relevant test when it's ordered. If you're tight for space:

• Put the diagnostic equipment in refraction lanes, but only schedule diagnostic tests when no doctor will be using that lane (do not take the lane away from a doctor who is working). Such a test could be scheduled first thing in the morning, at lunchtime, or on a doctor's day off.
• Eliminate equipment whose studies provide you a minimal margin of profit and which you can easily order elsewhere.

Necessary overhead space. These are spaces that you need to serve the patient or doctor and directly affect patient flow. The waiting room is a great example of this type of space. If you're tight for space:

• Make sure the doctors' patient-per-hour output is in sync with the appointment schedule. If the appointment book brings patients into the practice faster than the doctor puts them out, they and their families will tend to overflow the waiting room. Responding to this problem could cause you to make the waiting room larger than it needs to be.
• When patients make their phone appointments, ask them to come with only one family member. This will allow you to make the waiting room a little smaller.
• Use a billing service, or have billing done in the evenings. This way, the billing staff can use vacated business office desks to perform their duties.
• Let the doctors and staff members share a bathroom.
• With the new HIPPA regulations on patient privacy, instead of having a private interview space for taking new patient information or updating existing patient information, go back to the old clip board for patient information. Batch the results and have another business office staff member enter it into the computer.

Unnecessary overhead space. These are spaces that aren't of any real value to the primary function of the office. If you're tight for space:

• Probably the most discussed topic in this category is physician private offices, especially in surgical practices. In many such practices, these rooms are infrequently used. Some practices have eliminated them altogether. Others are putting individual desks into one "bull-pen."
• Another possibility is the doctor conference/library room. If you have conferences only once or twice a month, consider using the waiting room or staff lounge. You can also use a private room at a local restaurant or the hospital.

And instead of an enclosed library, consider widening the hallway near the doctors' offices by 12 inches and lining the wall with bookshelves.

• Reconsider the inclusion of superfluous spaces like an exercise room. It may be an important part of your personal lifestyle, but if you're short on space you can meet this need elsewhere. (I don't consider the staff lounge in this category. It's important to staff welfare. If you need to scale it back, consider having a coffee bar, at least.

And a final, general tip: It's a more efficient use of space to have a hallway serve rooms on both sides. This is referred to as a double-loaded hall vs. a single-loaded hall.

Don't jump into remodeling

If you've made as many changes as possible, still don't have enough space, and are considering remodeling, be careful of how you spend your remodeling dollars. For example, if you have a wall in your office that's in the wrong place and you want to move it, remember: Your equity in that wall is carted to the dump, and the amount you still owe the bank has yet to be repaid. To build your new wall, you'll have to contribute your new equity portion of the cost of that wall, and you'll have to repay the bank for the new amount you borrow.

So, if you're going to remodel, I recommend that you get a lot of mileage out of very little remodeling. Otherwise, you may spend yourself into a problem.

Richard C. Haines, Jr. is the president of Medical Design International in Tucker, Ga. You can reach him at (770) 939-7950.

Squeezed for Space?
Renovations or new "traffic" patterns can make your practice feel larger.
By Larry Funston

Expansion or relocation may not be an option when your office is too small. However, you can still find alternatives for relieving crowded, inefficient areas. In this article, I'll suggest some solutions that either minor renovations or reworked traffic flow can provide.

Let's start with a few ways to renovate:

	In this practice, the problem of a low ceiling and a ceiling air conditioner was solved by installing a bronze mirror outlined by feature lighting. Optical dispensing and reception are back-to-back, creating an open, functional dual-purpose island.

Create openness. The perception of tight space is oppressive to everyone. A sense of openness can relieve that cramped feeling. You can create visual openness by replacing solid walls with glass walls while, at the same time, allowing privacy where needed. Use a combination of lighting change, ceiling height variations, floor finishes, and mirrors to accomplish the feeling or more space. Varying ceiling heights can announce a featured area. Changes in flooring from tile, carpet, and carpet with borders can define and direct traffic.

Contemporary lighting techniques are very effective in defining space in a small office. Traffic and non-service areas with lower ceilings, softer lighting and bordered carpet leading to brighter service areas with higher ceilings and a change in flooring suggest the movement desired through the practice.

Patients feel more at ease in an open environment for a number of reasons. They actually enjoy watching the goings on. They're apt to become interested in services you offer that they haven't yet used. Staff will also be more comfortable, and they'll have visual contact with the other service areas in the office, enabling them to respond quickly to staffing needs.

Traditionally enclosed spaces, such as exam rooms, can benefit from a windowed wall. If the room is small, with mirrored lanes, the windowed wall will relieve the closeness. Likewise, on the hallway side of the exam rooms, the windows have the same effect. The hall will not feel as narrow or unfriendly. The windows can have blinds or tinted glass to help achieve the lighting levels required for the exam room.

Think outside the box. In office buildings or rented space, and even in new buildings, there are always limitations. Whether they are dictated by the size and shape of the space or lot, surrounding landscape and buildings, external traffic patterns, features of an existing building, landlord stipulations, or other issues, it is a certainty that limitations exist.

Don't allow what you consider a given (something that has to stay) to drive your office design. Explore the possibilities vs. the costs.

A small office may seem smaller because a stairwell is in the middle, or a washroom divides clerical space. Moving these seemingly immoveable objects can be done and is often desirable. Doing so could become a tremendous advantage in the overall office design. Don't be limited by these situations.

A classic example of overcoming barriers is the story of a Montana practice I worked with in 1999. The doctors were stymied by load-bearing walls. A poorly designed layout that seemed unchangeable was preventing them from using all of their space effectively. A hallway with a vaulted ceiling ran half way down the center of the building. Reception with check-in and check-out, pre-testing, exam rooms, and offices occupied half the building. Patients and staff were moving back and forth in the same space. The optical department was out the door and across the vaulted hallway into another door.

We were able to replace the load-bearing walls with beams, eliminating the hallway and opening the entire area. Once this concept was in place, 100% of their space opened up. The practice gained two additional exam rooms. The optical department became an integral part of the practice, increasing its sales dramatically.

Improving staff and patient flow

If these types of renovations aren't possible for you at this time, you can still reconsider the traffic flow through your practice to maximize the space you do have. The first rule in planning traffic or flow in cramped space is to minimize the percentage of staff and patient walk-through space as compared with useable space. You can accomplish that by:

Separating staff movement from patient flow. It's possible to do this through the arrangement of staff areas, thus avoiding patients and staff having to use the same narrow hallway. This is sometimes achieved by locating staff and patient records in the center of the available space, while arranging patient services around and outside staff areas. Patients move in a circular flow from reception to pretesting, then exam rooms and patient education areas to optical services, all wrapped around the outside of the business office, tech stations, and doctors' offices.

From a marketing point of view, a patient will be less than impressed with the confusion and crowded feeling caused by two-directional traffic in a hallway. From a management point of view, you save staff time from being eaten up by the inefficiency of additional movement.

Making movement sequential. Always try to keep patient flow going in one direction. One effective traffic controller is interior waiting. Seating near exam rooms, for example, can minimize traffic for the doctor, staff and patient. These niches can have multiple uses. For example, they can be a holding area for dilating patients or patients in contact lens trials, thus eliminating the need to return the patient to the reception area while waiting. These are also convenient places for patient education and informed consent presentations.

Making a little space go a long way. When space is allocated based on patient services and potential income, space for staff tends to shrink. However, you can maximize that space by designing small, flexible, functional areas through the use of drawers, cabinets, handy electrical outlets and lighting specifically suited to staff tasks.

Sharing space. Organized in the manner described above, clerical space can have multiple uses at various times of the day or days of the week. Medical transcription, for example, can rotate with bookkeeping or third-party billing.

Patient education/training areas are also prime candidates for shared space. You could use an area for LASIK patients part of the week and cataract patients the rest of the week. A contact lens fitting room can also serve as a surgery follow-up examination room.

Think about the future

Whatever changes you decide to make, remember that provisions you don't need today, you may need in the future, and so you should include them in your redesign. Services such as installing an in-house finishing lab or adding automated refraction may be part of your 5-year plan and need to be included in today's design.

At the same time, calculate growth over the next few years and weigh it against the time you would need to earn an adequate return on the investment made in the redesign. This will allow you to forecast when you will again reach capacity and answer the vital question: Does the practice have enough time before another solution is needed to realize the benefit of this investment?

The redesigning of small, awkward space into open, inviting, more efficient space can have a profound effect on your practice. Change is always stimulating to business. You and your staff will benefit as well because you will be working in a more pleasant environment. You may also notice increased productivity, improved attendance, and lower staff turnover when you use the latest and best design techniques for solving space problems.

Larry Funston is an ophthalmic office designer with Oadbe Associates, Ltd. in Mississauga, Canada. You can reach him at his U.S. office: (859) 879-3407.