Designing a new hospital outpatient centre
A co-design approach was used for the Ambulatory Care Centre in London. Oliver Marlow and Kursty Groves explain how this created a better space for patients and staff, expanding this hospital’s treatment capabilities.
The Whittington Health Trust, recognising that demand for acute care services was rising among the 500,000 people in its service area and in response to a shift in focus by the National Health Service (NHS) around integrated care, opted to build a new Ambulatory Care Centre adjacent to its existing hospital. This new outpatient centre opened in 2014, expanding the Whittington’s same-day treatment capabilities, whilst at the same time bringing different departmental disciplines closer together and improving the patient and staff experience.
The facility is concerned mainly with patients who have medical illnesses and need to be admitted to hospital, as well as patients who need services in the community. The initiative aims to produce a more integrated experience for patients – referred to as ‘integrated care’ – providing a better, less fragmented patient experience than the traditional NHS approach and, ultimately, avoiding unnecessary hospital admissions. The simple goal is to wrap services around the needs of the patient, meaning that when a patient enters with an illness or a collection of symptoms, which require certain investigations or specialist opinions, as far as possible the experience will be a one-stop shop.
Yet, during the early development of this new, relatively ambitious approach, it became apparent that the physical environment was actively limiting the development of the model. As Clarissa Murdoch, Clinical Lead for Ambulatory Care and Clinical Director for Acute Care recalls: "The reality was that the patients who were likely to most benefit from having an ambulatory care model were really being looked after in our broom cupboard when we were in our very small, two clinic rooms."
Amongst the project’s remit was a layout designed around the patients’ needs, staff requirements and smooth departmental flow. The design also needed to create a calm atmosphere, as well as accommodate the latest equipment.
When you come to a healthcare institution, I don’t think you want to see an intimidating, traditional hospital environment. I think it’s very refreshing to see a light and airy environment like this but it also changes the way the clinicians work.
Challenging the traditional healthcare environment, the new centre improves the patient experience in many ways, including direct access to natural light and natural ventilation within as many areas as possible. "You walk in and it’s light and airy, it’s colourful – which is not very NHS. It feels very welcoming," says Richard Jennings, Divisional Director for Integrated Care and Acute Medicine. "It isn’t covered in posters and leaflets – if we’re giving our patients information, we’re giving it directly from the specialists who know the information in a way that has a totally different feel to a traditional NHS environment. I think that matters to our users very much. When you come to a healthcare institution, I don’t think you want to see an intimidating, traditional hospital environment. I think it’s very refreshing to see a light and airy environment like this but it also changes the way the clinicians work." A simple switch of corridor and treatment room, for example, means that it is the rooms that receive the natural light and ventilation rather than the corridor.
The project team also focused on addressing issues, such as water and energy efficiency, improving the building’s insulation and providing a sustainable lighting system. The layout allows natural light to penetrate the depth of the space, helping to create a non-institutional setting while also reducing the need for extra artificial light sources. The flow of the unit is shaped as a ‘figure of eight’ around a central communal zone, separating adult and paediatric areas, and passing by all of the cubicles and treatment rooms, which enables infection control and easy mobility for staff and patients. Many areas are multifunctional: the children’s play area also serves as a designated observation zone where children can be treated with ease whilst absorbed in play.
The centrally-positioned communal cafe space and waiting area is designed similarly, with a centralised nurses’ station incorporating both 360-degree observation and a glazed area for private conversations between doctors and nurses that afford patient dignity. "This balance of auditory and visual connection ensures their safety and stability from a clinical point of view, while at the same time they can connect and see us, and feel reassured. But also there is a clear area that is private, where staff can talk and respect patient confidentiality," explains Nathalie Richard, Consultant in Emergency Medicine and Joint Ambulatory Care Lead. "It is a very subtle thing and could very easily have been missed. It’s all part of us trying to create the best experience."
"What we have now is a unit where we can observe patients through the daytime. We can actively treat them, but not in a way that’s restricted to a bed space," continues Giles Armstrong, Consultant Paediatrician. In the central zone, wi-fi enabled devices are made available to people, allowing them the opportunity to learn about their conditions rather than feeling like they’re just waiting. A centrally-located phlebotomy (blood-taking) booth combines so much of what is successful about the new centre. While private when necessary, it is positioned directly in the communal space – demonstrating the centre’s challenge to clinical traditions of keeping treatments, waiting and administration separate. "Nobody thinks that having a blood test is a pleasant experience but if you can make it a seamless part of the patient journey then that’s fantastic," says Murdoch. "The phlebotomy booth was put in the middle so that the interaction can happen at any point – but it is also key that it's all happening around a central, friendly flexible space."
What we have now is a unit where we can observe patients through the daytime. We can actively treat them, but not in a way that’s restricted to a bed space.
Local artist Alex Green produced a series of murals which both transform and enhance clinical areas, places in which patients are required to sit, wait and spend time, creating a calming air and visual points of interest. Calling upon his own notions of relaxation, the aim of the murals was to soften the clinical, and often stressful, hospital space by putting day-patients at ease in a more informal environment.
A critical part of the design approach was partnering, most importantly, with the patients, as well as carers, doctors, social care, mental health and other healthcare providers. Working with patient cohorts, the team began looking at individual care pathways. For example, discussing conditions and observing the important interactions that patients have during their journey pre-hospital, through the hospital, and then looking at how the process could be made that better. The hospital then commissioned architecture and design practice Studio TILT to employ a co-design approach for the facility. As part of this process, workshops were held with people across the hospital trust, including managers, clinicians, administrators, infection control staff and – of course – patients, to gather clinical insights and experiences. These ideas were then tested within full-scale mock-ups.
Meeting regularly throughout the design process meant that initial ideas that were sparked by patient and clinician perceptions were kept in sight: "Sometimes there were little things that came up and we could say, hang on, stop, that’s not the purpose of it," recalls Murdoch. "So for instance, in the dual-function clinic rooms, we were able to say that we needed quite basic things like being able to examine the patient from the right-hand side of the bed. People don’t appreciate quite how important that is for doctors, but actually that’s really essential – and it’s not the most obvious thing to people who aren’t clinicians. There were lots of examples like that in the design process where being involved at an early stage allowed us to have a lot of two-way conversations where, if there was something we knew wouldn’t work, we could ask what could be offered as an alternative – and that felt really important."
This attention to engagement throughout the process has paid off, as Murdoch explains: "I think it’s been a success from the point of view that it has delivered a really good patient experience: we get fantastic feedback, and it works for the clinicians that are working here. This space has led to an expansion of the model in that it has encouraged clinicians from across the hospital to look at how they’re delivering care and how they might do it differently."