Can New Offices Change a Group's Practice Style?
Azevedo, David, Medical Economics
Forced to abandon its cramped, outdated buildings, this group designed its beautiful new digs with managed care in mind.
t's a question that could have appeared on this year's MCATs: If a pediatrician left her department to staff an after-hours urgent-care center at 5 p.m., a plastic surgeon began making his way toward a department-head meeting at 5:01, an orthopedic surgeon left the surgery center for his office at 5:02, an FP began trekking to consult with a staff psychiatrist at 5:03, and all the doctors were members of the same group, where would they meet? The answer, if the group happens to be the Palo Alto (Calif.) Medical Clinic, is in downtown Palo Alto. That's because all the doctors involved would have to walk local streets to reach their destinations.
Some 13 buildings across three city blocks comprise the current home of the Palo Alto Medical Foundation (the clinic is the organization's physician arm). The main building, a three-story rectangle that "looks like the box the rest of the buildings came in," according to one Palo Alto physician, was appended to the group's original Spanish-style clinic in 1962. Over the years, when that setup proved too small, the group branched out.
The clinic's doctors will be united later this year when PAMF unveils its new $100 million main campus. (It will also continue to operate two satellites.) Prodded by California's building codes, which would require tens of millions worth of upgrades for the old buildings to meet earthquake safety standards, Foundation leaders began looking at solutions to their space problems a decade ago. They ultimately settled on a nine-acre site only six blocks from their present home.
PAMF, located about 30 miles south of San Francisco, sits in the vortex of two of the most compelling issues in medicine-managed care and computer technology. The move allows the group to accommodate both in the design and planning of the building. Hundreds of hours of meetings gave Palo Alto doctors a chance to contribute to the building's design. And while the new campus won't revolutionize how the clinic's doctors work, it does represent an evolutionary step toward tomorrow's medical practice.
Who's next to whom stirs debate
For the 150 or so Palo Alto Clinic doctors who will move to the new building, significant changes await. Some departments, such as plastic surgery and sports medicine, will be moving from their private enclaves into a large group setting.
Perhaps no department's physical surroundings will change more than those of the psychiatric department. For now, Palo Alto's mental health practitioners work in a charming Victorian house a block from the main clinic building. The house boasts wood paneling, fireplaces, and a private, cozy feel.
"That house served us well when psychiatry had nothing to do with primary care," says internist David Hooper, a member of the clinic's board of governors. "But under managed care, psychiatry needs to interact more with primary-care physicians. In the new building, mental health will be next to family practice, allowing psychiatrists and counselors to participate in managing common primary-care issues like depression. The trade-off is that they lose their house full of character and move into a more sterile office setting."
Adjacencies-both intra- and interdepart-, mental-were much debated issues among the group's doctors. Family practice leaders, for example, wanted to be next to pediatrics so the two departments could share a kids' play area. Because of various considerations, it didn't work out. "Our patients can't access a play area; that's a real disincentive for parents to have FPs care for their children," says FP Steven Lane.
Family practitioners also wanted to be near the general internists so that all adult primary care would be centralized. Internists, though, had other ideas. "We wanted to remain with the internal medicine subspecialists, because so many of our patients are complex and involve subspecialty care," says Barry Eisenberg, Palo Alto's chair of general IM.
"We benefit from easy communication with our specialists," Eisenberg continues. "To be physically separated would interrupt the flow of information that we depend on." In the end, the internists won out; they'll occupy the second floor of the new building, alongside their subspecialty colleagues.
The structure won't exactly replicate what's currently used at the clinic, however. Because expansion has come over time, not all general internists in the old building are together. In the new facility, they will be. "In our current space, primary-care internists are sprinkled around, so you'll have a pocket of generalists next to a covey of specialists next to another pocket of generalists, and so on," notes rheumatologist Mel Britton, chair of the clinic's medical subspecialties. "I'm worried about the isolation of generalists and specialists in the new building. I'd hoped it would create more contact among subspecialists, but doctors wanted to be with others in their specialty."
Some Palo Alto doctors explored an almost random distribution of specialties throughout the building. "It would have been quite interesting from a practice standpoint to be next to someone in a different specialty," says FP chair Susan Smith. "But the scheduling, phone coverage, and equipment concerns made that idea a practical impossibility."
Who's running the show? Patients, of course
Such an approach also would have run counter to a recurring theme in the group's design of its new offices: Instead of building a structure to suit physicians, the facility will cater to patient needs. "The premise behind all decisions was that we wanted the building to bring the doctors to the patients, not vice versa," says dermatologist David Druker, PAMF's chief operating officer. "We wouldn't have paid as much attention to the patient perspective 10 years ago, but we're very conscious of patient satisfaction now and have tried to make the building as userfriendly as possible."
For example, notes Druker, high-volume specialties such as family practice, Ob/Gyn, pediatrics, and urgent care are in easily accessible areas on the main floor. Another concession to patient convenience is placing X-ray equipment outside the radiology department. "We wanted all the imaging equipment in one place so we could operate it as efficiently as possible," says radiology chief Solon Finkelstein. "But we talked to people in orthopedics and urgent care and decided to have machines in those areas, too. It requires more units and personnel, but it's what's best for patients."
Happily for some group physicians, patient convenience often turns out to mean physician convenience as well. For example, the clinic's surgicenter-currently offsite-will be housed on the new campus, saving both patients and doctors countless trips for ambulatory procedures. After-hours pediatric urgent care, which for now is across the street from the main clinic building, will be right next to the pediatric department in the new facility.
Despite the changes, most Palo Alto doctors' practices won't change fundamentally with the move-and that disappoints a few in the group. "There were a lot of ways we could retool a medical building to take care of populations of patients, and we're not doing them," asserts Steven Lane. "We're not creating multidisciplinary pods of family doctors, surgeons, and subspecialists taking care of a specific population of patients. We're not really incorporating mental health into the flow of primary care or bringing urgent-care services into the primary-care departments so people can see their regular doctor.
"This is a solid organization with good leaders, but its stability can also be a pain when you're a person with new ideas." He nevertheless remains sanguine about the group's future. David Hooper agrees: "I thought the new building would radically change the way we function, but it won't. I think we need a more radical change, but the culture of the organization isn't quite there yet.
"For example, we need more rooms that allow doctors to meet with groups of patients, not just one-on-one encounters. We originally designed in a good number of these rooms, but ultimately doctors didn't want to give up the exam space. A lot of physicians aren't ready for the changes that are coming."
As times change, so will the building
Hooper does note that the building isn't static. "It's designed to allow us to practice as we do now, but it can evolve to new functions down the road," he says.
Adds Jenifer Tumbull, PAMF's manager of business planning and development: "We tried to avoid what we have in the old buildingevery department with its own kind of space. We planned around a standard module that will easily accommodate anticipated changes. So exam rooms can convert to shared group rooms, if needed, with little trouble."
The flexibility extends to individual departments. "We tried to put together departments we thought would shrink with those that will expand," says Hooper. "Medical records will be next to our surgery center, because record-storage needs will shrink with the adoption of the electronic medical record, and surgery-center space will expand as technology allows us to do more procedures outside the hospital."
Technology, particularly computer advances, has been at the forefront of much of Palo Alto's building strategy. Every exam room, office, and nursing and dictation station is hard-wired with the latest computerconnection cabling, and doctors eventually will have lightning-speed Internet connections. Waiting rooms will be equipped with computer kiosks to facilitate patient education.
"We've tried to integrate patient education and wellness throughout the facility," says Turnbull. "For instance, we'll have a special patient-education room where people can watch videos and talk to a nurse about health questions. That's something we just don't have room for at our existing site." The group is also talking about adding a building on its campus to serve as a community wellness center, says COO Druker. Such efforts are an outgrowth of managed care and capitation. "Under fee-for-service, we never would have done all the things we're doing to promote prevention and education," says Druker.
ile moving to a new campus is exciting for Palo Alto doctors, they won't leave their current hodgepodge of homes without some hesitation. "I'm looking forward to working in a new, clean, modern building," says Steven Lane. "But it's more sterile and institutional than we're used to. Doctors' offices are all alike, and windows don't open. I hope we don't lose our personality in the bigness and typicalness of the building."
David Druker also worries about how the move may affect the group's character. "Our present space has a nice residential neighborhood feel to it," he says. "Traffic isn't bad, and there's an unhurried atmosphere. At the new site, patients will be coming off a busy street right into an underground parking garage. We may lose some of the friendly, homey approach we've tried to promote. It will be a challenge to hold on to that.
"Overall, though, the new campus should enhance pride in the organization, and I think doctors will enjoy coming to work there. That's not always an easy thing for doctors to say these days."
Group Practice Economics is edited by Anita J. Slomski, Midwest Editor.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Can New Offices Change a Group's Practice Style?. Contributors: Azevedo, David - Author. Magazine title: Medical Economics. Volume: 75. Issue: 3 Publication date: February 9, 1998. Page number: 83+. © Advanstar Communications, Inc. Jan 23, 2009. Provided by ProQuest LLC. All Rights Reserved.
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