D.34 Space Planning Criteria CBOCs.pdf

PG-18-9 – SPACE PLANNING CRITERIA October 1, 2021 265 – Community Based Outpatient Clinic (CBOC)

CHAPTER 265: COMMUNITY BASED OUTPATIENT CLINIC (CBOC)

1 PURPOSE AND SCOPE ................................................................................................. 265-2

2 DEFINITIONS............................................................................................................... 265-2

3 OPERATING RATIONALE AND BASIS OF CRITERIA ......................................................... 265-9

4 INPUT DATA STATEMENTS (IDS) ................................................................................ 265-15

5 SPACE PLANNING CRITERIA....................................................................................... 265-15

6 PLANNING AND DESIGN CONSIDERATIONS................................................................ 265-47

7 FUNCTIONAL RELATIONSHIPS ................................................................................... 265-50

8 FUNCTIONAL DIAGRAM ............................................................................................ 265-51

1 PURPOSE AND SCOPE

This document outlines Space Planning Criteria for Chapter 265: Community Based Outpatient Clinic. It applies to all Department of Veterans Affairs outpatient clinics commonly referred to as Community Based Outpatient Clinics (CBOCs). These clinics provide basic primary care and mental health services in addition to a widening array of other clinical and diagnostic services.

VA Mission Act: One component of the MISSION Act provides Veterans greater access to health care in VA facilities and the community. This legislation is intended to strengthen and improve VA’s ability to deliver health care to Veterans.

One consequence will be the strengthening and accelerating of the trend already in motion of distributing more services from centralized medical centers to clinics near to Veterans homes and the ongoing expansion of virtual care delivery.

Policy document: VHA Handbook 1101.10(1) Ammended May 26, 2017.

2 DEFINITIONS

Assisted Electronic Check-in: The operational model moving Veteran check-in actions from a queue-based staff-driven approach to a multi-channel Veteran-driven electronic check-in system. The devices are commonly kiosks with touch screens, but these may evolve to touch pads or other technologies in the future. In current best practice, staff and volunteers acting as greeters and guides are available at one or more prominently placed banks of kiosks to help Veterans to check-in without queueing. This places check-in under the Veteran’s control and speeds access to care. This approach supersedes the legacy check-in desk common in past design guidance. Ninety-eight percent assisted kiosk check-in rates are easily achieved. Time from arrival to rooming can be reduced by over fifty percent.

Back of House: Staff only spaces that support the general operations of the clinic but are separate from the direct moment-by-moment workflows in the clinical neighborhood teamwork area.

BHIP Team: The Interdisciplinary Program Behavioral Health Team is a collaborative, Veteran centered, coordinated care model. Team composition varies from five to ten staff and teams commonly contain psychiatry and/or other “prescribing staff”, psychologists, social workers, nurses, and clerical staff. A clinical pharmacy specialist may support one or more BHIP teams.

Corridor, Patient (Hallway): A controlled access hallway connecting the PCRs to the Main Street. Veterans / Family are escorted to the PCRs by staff members to insure privacy.

Veterans / Family enter the PCRs through the doorway from the patient corridor.

Clinical Neighborhood (CN): Is both a functional zone and a base clinic planning unit. It consists of patient hallways, patient care rooms, a teamwork area, and supportive spaces for team-based integrated clinical care. The clinical neighborhood, in its base configuration, is configured to support the widest range of clinical users.

Clinical Staff Workstation: A systems furniture based teamwork area, the staff member’s home base in the clinic. A specific space allocation for each Teamlet that in aggregate forms a major portion of the space in the Teamwork Functional Area. Each workstation has a minimum of five linear feet of worksurface, two computer monitors, a computer or docking station for a laptop, a telephone, and a storage cubby for personal items. A sit-stand function is preferred.

Colocation: Placing diverse team members in close physical proximity enhances collaboration, communication, camaraderie, and care coordination. A physical expression of this precept is the Teamwork Area in the Clinical Neighborhood.

Enrolled Veterans: Veterans listed in the Facility Registry

Extended Team: The PACT and BHIP teams, and all their allied colleagues in the CBOC. All extended team members working in a clinical neighborhood have a workstation in the teamwork area as their home-base in the CBOC.

Group Care: A term used broadly here to denote space for shared medical appointments, group therapy, patient educational, peer-to-peer, and wellness events involving more than one Veteran at a time. Demand for these events in constantly growing. A few examples include group based clinical care, weight loss classes, tai chi, yoga, dietary and food preparation training, and AA meetings.

Shared Group / Multifunction Room: Any room that could be used at any time to support group care and meeting activities. With rare exceptions all such rooms should be associated with the front-of-house areas with easy access by Veterans. It is a common practice to provide one or more large spaces and use high quality moveable acoustic partitions to subdivide the space into a variety of rooms.

Patient Aligned Care Team (PACT): A model of care providing service to Veterans that is patient-centered, is the right care at the right time by the right person. A typical PACT Team is comprised of several mutually supportive collocated PACT Teamlets. The PACT Team and Teamlet composition are evolving and membership is subject to change.

PACT Teamlet: A group comprised of a Provider (MD, NP, etc.), a RN-CM, an LPN or Health Tech and a Clerk assigned a panel of veterans.

Patient Care Room(s) (PCRs): Are on-stage rooms in which staff interact directly one-on-one with the Veteran to deliver care. In the VA design model, they are dual-door universal standardized base rooms. The specific functionality of the room is determined by the equipment and furnishings placed in the room. In this model we say that “patient care rooms belong to the Veterans,” where the focus needs to be.

Point-of-Use: As distinct from bulk storage, utility, and prep areas in the back-of-house, point-of-use spaces are rooms, alcoves, and/or dispensing units as near to the point of shared need in a CN as practical. Uses range from places for printers and supplies, medications, and equipment such as the EKG machine.

Teamwork Area: The off-stage in-flow open shared teamwork area for all extended team members. Each full-time team member has an assigned workstation collocated with their teammates to foster communication and collaboration. Part-time, trainee, and hoteling staff may share workstations assigned for that purpose. The teamwork areas are open so staff are visually connected and can see the status of each PCR. All PCRs are connected to the teamwork area and are entered by the staff door from the teamwork area. Supportive spaces for point-of-use supplies, medications, and equipment complete the space.

Telehealth: A wide range of means to connect indirectly with the veteran in locations removed from the staff person engaging the Veteran including secure messaging, telephone clinics, and video visits. May involve highly specialized equipment, in home VA supplied devices, and special multiple monitor displays, but most commonly is just a computer or smart phone used by each participant.

Veteran Appreciation Area: One or more spaces in a clinic dedicated to displays that reflect military service and our shared pride in our Veterans and VHA’s mission to provide their health care. These are often a wall with locally made displays. Examples include “Purple Heart Walls” with voluntarily contributed photos and histories of local Veterans awarded the Purple Heart for their service, displays of uniforms and memorabilia, and women Veteran’s history displays.

Video Connect: A scheduled or impromptu video visit between a Veteran and a staff member. Often initiated by the staff member sending the veteran a link to connect virtually.

This function shall take place in the Video Connect Station. Alternatively, this can take place in any Patient Care Room, as all PCRs are supplied with video connect equipment.

Volunteer Refreshment Station: In clinics not large enough to support a canteen based cafe’ or coffee shop a volunteer managed refreshment station is a critical amenity highly valued by the Veterans. This area often serves as a de facto social hub for the clinic. Volunteers are crucial to VHA’s mission and a key element in CBOC operations. Volunteers are critical in welcoming Veterans and placing our guests at ease. They provide refreshments, guide patients, staff information desks, and can assist at kiosks among other useful activities.

(Welcome Station & Refreshment Station)

Welcome Station Volunteers are crucial to VHA’s mission and a key element in CBOC operations. Volunteers are critical in welcoming Veterans and placing guests at ease. They provide refreshments, guide patients, staff information desks, and can assist at kiosks among other useful activities.

Workstation, Staff Hoteling: A slightly smaller workstation for partial FTEE workers or those with limited time in the clinic. Often placed toward the rear of the clinic and combined with the huddle space.

Workstation, Trainee: A slightly smaller workstation for partial FTEE workers or those with limited time in the clinic. Often placed toward the rear of the clinic and combined with the huddle space.

Space Planning / SEPS Accessible: A site, building, facility, or portion thereof that complies with provisions outlined in the Architectural Barriers Act of 1968 (ABA).

Architectural Barriers Act (ABA): A set of standards developed to ensure that all buildings financed with federal funds are designed and constructed to be fully accessible to everyone.

This law requires all construction, renovation, or leasing of sites, facilities, buildings, and other elements, financed with federal funds, to comply with the Architectural Barriers Act Accessibility Standards (ABAAS). The ABAAS replaces the Uniform Federal Accessibility Standards (UFAS).

Average Length of Encounter (ALoE): Averaged length of time, in minutes, a patient spends in an Exam / Treatment Room interacting with a provider and the clinical support team. It is accounted from room “set-up” to “clean-up” by staff. This metric is used to determine the number of annual patient / provider encounters that take place in an Exam / Treatment Room which, in turn, is used to calculate the number of Exam / Treatment Rooms needed in a facility based on projected annual workload. The ALoE is determined with VHA SME input during a PG-18-9 clinical chapter revision / update.

Average Length of Stay (ALoS): The average number of days a patient Veteran stays in an inpatient care unit. The ALoS is used to calculate the number of patient bedrooms for a specialty by dividing the site’s projected workload by the ALoS.

Building Gross (BG) Factor: A Factor applied to the sum of all the Departmental Gross Square Footage (DGSF) in a project to determine the Building Gross Square Footage. This factor accounts for square footage used by the building envelope, structural systems, horizontal and vertical circulation including main corridors, elevators, stairs and escalators, shafts, and mechanical spaces. The Department of Veterans Affairs has set this factor at

1.35 and included guidance in case of variance when developing a Program for Design (PFD) in SEPS.

Clinic Stop: Per these criteria, a clinic stop is the workload unit of measure for space planning. Clinic Stops are codified by VSSC, when applicable, they are referenced by number in the calculation of workload driven patient care spaces in this document.

Department Net to Gross (DNTG) Factor: A parameter, determined by the VA for each clinical and non-clinical department PG-18-9 space planning criteria chapter, used to convert the programmed Net Square Feet (NSF) area to the Department Gross Square Feet (DGSF) area.

Encounter: An interaction between a patient Veteran and a VA provider or providers in an Exam Room / Treatment Room / Consultation Room / Procedure Room, spaces where a patient Veteran received clinical care.

Full-Time Equivalent (FTE): A staffing parameter equal to the amount of time assigned to one full time employee. It may be composed of several part-time employees whose combined time commitment equals that of one full-time employee (i.e., 40 hours per week).

Functional Area (FA): The grouping of rooms and spaces based on their function within a clinical service or department.

Functional Area Criteria Statement (FACS): A verbalized mathematical / logical formulation assigned to a FA incorporating answers to Input Data Statements (IDSs) to determine the condition for providing the rooms / spaces listed in the FA in the baseline space program or Program for Design (PFD) for a project. Certain rooms / spaces may or may not have additional conditions.

Huddle Space: A multi-use space, often placed at the rear of the teamwork area, used for extended team huddles, precepting, local neighborhood staff training, and team projects.

Often combined with trainee/hoteling staff workstations. May double as the trainee workroom when students or trainees are present.

Input Data Statement(s): A question or set of questions designed to elicit information about the healthcare project to generate a Program for Design (PFD) based on the parameters set forth in this set of documents. This information is processed through mathematical and logical operations in the VA Space and Equipment Planning System (SEPS).

JSN (Joint Schedule Number): A unique five alpha-numeric code assigned to each content item in the PG-18-5 Standard. JSNs are defined in DoD’s Military Standard 1691 and included in SEPS Content Table.

Net Square Feet / Net Square Meters (NSF/NSM): The area of a room or space derived from that within the interior surface of the bounding walls or boundaries.

Patient Unique: (or Unique Patient), A Veteran patient counted as a unique in each division from which they receive care. Patient Uniques are included in the Registry for a VA Medical Center.

Program for Design (PFD): A project specific itemized listing of the spaces, rooms, and square foot area required for the proper operation of a specific service / department, and the corresponding area for each. PFDs are generated by SEPS based on the PG-18-9 Standard.

PG-18-9: A Department of Veterans Affairs’ Program Guide for the Space Planning Criteria Standard use to develop space planning guidance for the planning, design, and construction of VA healthcare facilities; a Program Guide (PG) that provides space planning guidance for VA Medical Centers (VAMCs) and Community Bases Outpatient Clinics (CBOCs). PG-18-9 is organized by chapters, as of September 2021 there are 56 clinical and non-clinical PG-18-9 chapters; they are implemented and deployed in SEPS so that space planners working on VA healthcare projects can develop baseline space programs.

PG-18-5: A Department of Veterans Affairs’ Equipment Guidelist Standard for planning, design, and construction of VA healthcare facilities; a Program Guide (PG) that lists assigned room contents (medical equipment, furniture, and fixtures) to each room in PG-18-9. PG- 18-5 follows PG-18-9’s chapter organization and nomenclature.

PG-18-12: A Department of Veterans Affairs’ Design Guide Standard for planning, design and construction of VA healthcare facilities, a Program Guide (PG) that provides design guidance for VA Medical Centers (VAMCs) and Community Bases Outpatient Clinics (CBOCs).

The narrative section details functional requirements and the Room Template section details the planning and design of key rooms in PG-18-9. Not all PG-18-9 chapters have a corresponding PG-18-12 Design Guide; one Design Guide can cover more than one PG-18-9 chapter.

Provider: An individual who examines, diagnoses, treats, prescribes medication, and manages the care of patients within his or her scope of practice as established by the governing body of a healthcare organization.

Room Area: The square footage required for a clinical or non-clinical function to take place in a room / space. It takes into account the floor area required by equipment (medical and non-medical), furniture, circulation, and appropriate function / code-mandated clearances.

Room area is measured in Net Square Feet (NSF).

Room Code (RC): A unique five alpha-numeric code assigned to each room in the PG-18-9 Standard. Room Codes in PG-18-9 are unique to VA and are the basis for SEPS’s Space Table for VA projects.

Room Criteria Statement (RCS): A mathematical / logical formulation assigned to each room / space included in PG-18-9 incorporating answers to Input Data Statements (IDSs) to determine the provision of the room / space in the baseline space program or Program for Design (PFD) for a project.

Room Efficiency Factor: A factor that provides flexibility in the utilization of a room to account for patient delays, scheduling conflicts, and equipment maintenance. Common factors are in the 75% to 85% range. A room with 80% room efficiency provides a buffer to assume that this room would be available 20% of the time beyond the planned operational practices for this room. This factor may be adjusted based on the actual and/or anticipated operations and processes of the room/department at a particular facility.

SEPS: Acronym for Space and Equipment Planning System which produces equipment lists and Program for Design for a healthcare project based on specific information entered in response to Input Data Questions.

SEPS Importer: A style-based format developed to allow upload of RCSs and IDSs to SEPS to implement and operationalize space planning criteria in PG-18-9 in the SEPS digital tool.

This format establishes the syntax used in the RCSs and allows the use of Shortcuts.

Shortcuts allow developers of space planning criteria statements to simplify RCSs making full use of their logical and mathematical functionality. A shortcut can refer to an RCS, a room in any FA or a formula. Shortcuts are [bracketed] when used in FAs and RCSs and are listed along with their equivalences at the end of the Space Planning Criteria section.

Space Planning Concept Matrix (SPCM): A working document developed during the chapter update process. It lists all the rooms organized by Functional Area and establishes ratios between the directly and the indirectly workload driven rooms for the planning range defined in this document. The matrix is organized in ascending workload values in ranges reflecting existing facilities and potential future increase. Section 5 of this document Space Planning Criteria reflects the values in the SPCM.

Stop Code: A measure of workload including clinic stops forecasted by the Office of Policy and Planning (OPP) for all Strategic Planning Categories at Medical Center and Outpatient Clinic levels.

Technical Information Library (TIL): The Office of Construction & Facilities Management (CFM) provides support for all major construction and lease projects. The TIL contains design and construction standards for the Department of Veterans Affairs. The TIL is aimed at VA employees in medical centers, community based clinics, regional offices, and national cemeteries as well as A/E consultants and provides relevant technical information for project development. Department of Veterans Affairs Technical Information Library (VA

TIL).

Telehealth: The use of technology, such as computers and mobile devices, to manage healthcare remotely. It includes a variety of health care services, including but not limited to online support groups, online health information and self-management tools, email and online communication with health care providers, remote monitoring of vital signs, video, or online doctor visits. Depending on the concept of operations for this space, it may be equipped as an exam room or as a consult room with video/camera capability.

Utilization Rate: A factor used in the calculation of a directly workload-driven room throughput. It represents, in a percent value, the room is idle based on the planning assumptions. For example, if a directly workload-driven room is available for use 8 hours a day, the Utilization Rate represents the assumed time it will be used, an 85% utilization rate indicates, for planning purposes, the room will be used 6.8 hours a day. An additional directly workload-driven room will be provided in the calculation once the previous room has reached 100% utilization. The utilization Rate is embedded in the Room Throughput value calculated in Section 3 of this document.

VA Room Family (VA RF): An organizational system of rooms / spaces grouped by function, a ‘Room Family’. There are two “Orders” in the VA RF: Patient Care and Patient Care Support;

Patient Care features four sub-orders: Clinical, Inpatient, Outpatient and Residential Clinical.

There are also four sub-orders in the Patient Care Support order: Building Support, Clinical Support, Staff Support and Veteran Support. Each room in a Family has a unique Room Code and NSF assigned based on its Room Contents and function which correspond to the specific use of the room. The same RC can be assigned to different Room Names with the same function in this document and can be assigned an NSF that varies based on the PG-18-5 Room Contents assigned to the room.

VA Technical Information Library (TIL): A resource website maintained by the Facilities Standards Service (FSS) Office of Construction and Facilities Management (CFM) containing a broad range of technical publications related to the planning, design, leasing, and construction of VA facilities. VA-TIL can be accessed at: https://www.cfm.va.gov/TIL/ https://www.cfm.va.gov/TIL/

Workload: Workload is the anticipated number of procedures, clinic stops, clinic encounters etc. that is processed through a department/service area. The total workload applied to departmental operational assumptions will determine overall room requirements by modality.

Workstation: Area outfitted with equipment and furnishings, typically allocated 56 NSF each. Managers and other staff with no direct reports as well as part-time, seasonal, and job-sharing staff may qualify for a workstation. Such environments are particularly conducive to team-oriented office groupings. These environments work best when they have access to conference and small group meeting spaces.

3 OPERATING RATIONALE AND BASIS OF CRITERIA

A. Space planning criteria included in this Standard have been specifically developed for this Department / Service in a Department of Veterans Affairs healthcare facility based on established VHA policy and guidelines to define the scope of services provided for the existing workload demand as well as that in the foreseeable future. Rooms and Functional Areas are provided based on research of clinical and non-clinical activities performed in this Department.

B. Development / update of VA’s Program Guide (PG) standards is a research based effort executed with participation of VHA Subject Matter Experts (SMEs), VA-Construction and Facilities Management Office (CFM) professional staff and specialty consultants hired for the task. These space planning standards are based on current applicable VHA policies and guidelines, established and/or anticipated best practice standards, and latest medical technology developments. Workload metrics were tailored to satisfy current and anticipated veteran workload demand.

C. The space planning component of PG-18-9 is based on the Space Planning Concept Matrix (SPCM) which lists all the rooms organized by Functional Area and assigns room quantity (Q) and area (NSF) for a series of ranges corresponding to the smallest to the largest department for this service in the VA healthcare system in incremental size; each range corresponds to a workload parameter which determines the number and area of each directly workload-driven room. The remainder of the rooms in the range i.e., waiting, storage, staff workstations, etc. are determined by ratios to the resulting number of or NSF of the workload-driven rooms.

D. Sections 4 and 5 of these space planning standards as well as the PG-18-5 standard are implemented in the Space and Equipment Planning System (SEPS) and hosted at the MAX.gov website so planners working on VA Construction projects can develop single or multi-department projects based on these PG-18-9- and the PG-18-5 standards. Output from SEPS is through Space and Contents Reports; the Space Report is the Program for Design (PFD), the Content Report is the Project Room Contents (PRC). Inclusion of a Functional Area as well as Room quantity (Q) and determination of the room area (NSF) in the PFD is based on the projected Workload input which triggers calculations included in the Room Criteria Statements (RCSs). The RCSs are placed immediately after each room name, room code and baseline area (NSF). The PRC list the medical equipment, furniture and fixtures associated to each Room Code in the project. The PFD & PRC are the baseline requirements for the planning phase of a VA project based on a site’s projected workload for the target planning year. This chapter’s corresponding PG-18-12, Design Guide -if available- is intended for use during the design phase of the project.

E. Space planning criteria herein reflect the space allocation standards for any Community Based Outpatient Clinic (CBOC) project in the VA System of Care, as such it is not location specific and are applicable to all VA facilities providing accommodation for primary and specialty care in an outpatient setting.

F. Space Planning Criteria herein applies to a VA CBOC project range of between 1 and 30 Teamlets in increments of one Teamlet. A planner developing a space program for a project with a requirement above or below this range shall use these standards as a baseline and manually adjust the Program for Design as needed with support of the Office of Construction and Facilities Management (CFM).

G. Rooms provided to support the demand generated are organized in the following Functional Areas (FAs):

1. Outdoor Public Area,

2. Indoor Public Area,

3. Veteran Welcome Area / Main Street,

4. Café / Refreshment Area,

5. Veteran Education / Group Care Area,

6. Physical Medicine, Prosthetics & Orthotics Area,

7. Laboratory Medicine Area,

8. Imaging Area,

9. Patient Care Area,

10. Teamwork Area,

11. Logistics Area,

12. Police Area,

13. Management Area,

14. Staff Wellness Area,

15. Mobile Technology Area, H. Room Area (NSF / NSM) and quantity (Q) of each room for every CBOC size generated in the range above have been calculated in the Space Planning Criteria Concept Matrix;

they are reflected as conditions in the Room Criteria Statement(s) (RCSs) for each room in Section 5. Refer to PG-18-12, Appendix X for the Space Planning Criteria Concept Matrix.

I. Room Criteria Statements (RCSs) are triggered by answers to the Input Data Statements (IDSs) in Section 4 and generate a set of spaces whose quantity and area correspond to the number of projected Veterans enrolled in the Facility Registry.

J. Space Planning parameters and metrics in this document are based on the Community Based Outpatient Clinic (CBOC) Space Planning Criteria Matrix (SPCM) developed as the basis for this chapter. The CBOC SPCM lists all the spaces an outpatient clinic site would require; the quantity and NSF for each room is calculated based on the projected number of Veterans registered to receive outpatient care for the site. The SPCM is organized in 30 ranges, each range represents an incremental workload value, a panel, of 1,000 Veterans, this way all current VA CBOC sites are covered in the SPCM. The upper ranges are calculated for future facilities in case a higher workload is projected.

K. The SPCM metrics are translated into one (or more) Room Criteria Statement (RCS) for each room in Section 5 of this document. The SPCM Planning Range, the maximum number of directly workload-driven patient care rooms, in this document is 10. If a project shall require provision of workload driven rooms above the maximum range value refer to CFM for guidance. Rooms in this space planning document are organized in 5 Functional Areas (FAs).

L. Based on its intended function, each room / space is assigned a:

1. Room Name (RN),

2. Room Code (RC),

3. Room Area, the Net Square Feet (NSF) and its corresponding “soft metric” Net

Square Meters (NSM),

4. Unique Room Criteria Statement(s) (RCSs) correlated to answers to Input Data

Statements (IDSs), and

5. Room Comment as needed.

M. The Room Codes included in this chapter stem from the VA Room Family. A unique support space, that may have variable area, is assigned a unique Room Code, and adopts the square footage, as needed, correlated to the room contents assigned which in turn correspond to the range for those rooms. A unique clinical space or a direct clinical support room, i.e., control room, system components room, etc. typically does not feature variable NSF. Patient Care room names for rooms unique to this chapter end in “, CBOC”. Patient Care Support room names end in “, Bldg Sprt”, “Clncl Sprt”, “Stff Sprt”, or “, Vet Sprt”, correlating to Building, Clinical, Staff or Veteran Support room families.

N. Section 5, Sub-Section F lists the SEPS Importer Shortcuts used for implementation of Sections 4 & 5 in SEPS. These shortcuts are inserted into the Room Criteria Statement (RCS) for each room which upon upload into the Space and Equipment Planning System (SEPS) allowing planners developing VA healthcare projects to determine quantity and square footage of each room by performing mathematical or logical calculations.

Shortcuts refer Input Data Statements (IDSs), Rooms or calculation parameters stemming from the SPCM.

O. SEPS is accessible to government healthcare planners and private sector consultants working on VA HC projects during their Period of Performance (PoP) through the MAX.gov website; government provided Training is a requisite for access.

P. SEPS incorporates a Net-to-Department Gross factor (NTDG) factor of 1.55 for Community Based Outpatient Clinic and a Building Gross factor of 1.35 in the space calculation to generate the Department Gross Square Feet (DGSF) and the Building Gross Square Feet (BGSF) respectively for the project based on the aggregate resulting Net Square Feet (NSF) for each range. Planners can adjust the BGSF factor in SEPS; the NTDG factor is fixed.

Q. Refer to the chapter corresponding PG-18-5 Equipment Guidelist for the Room Content assignment for each room during the planning phase of a project.

R. Refer to the chapter corresponding PG-18-12: Design Guide, if available, during the planning and design phases of a project. Not all PG-18-9 clinical chapters have a corresponding PG-18-12 document, please refer to the VA-TIL.

S. The space planning and design Program Guides: PG-18-9, PG-18-5, and PG-18-12 are available at the Department of Veterans Affairs Office of Construction and Facilities Management (CFM) Technical Information Library (TIL) website.

T. These space planning criteria shift the space allocation model from a historic-encounter-driven clinical departmental based room-by-room build-up-room-by-room model to a projected enrolled-Veteran driven all-basic-space-inclusive model. For a given number of projected enrolled veterans these criteria provide a set number of rooms and spaces in each of four functional zones organized in related functional areas. These space allocations are based on experience from operations in the field and input from the program offices. They are intended to provide a complete space allocation for the typical services appropriate to the number of enrolled veterans. This provides the facilities planner and local leadership a strong starting point in their planning process.

The facilities planner can then judiciously adjust space as needed to support the addition or subtraction of specific services and functions based on locally determined priorities, resources, and patient needs.

U. Space Planning Criteria herein applies to a Community Based Outpatient Clinic (CBOC) project for an 850 to 30,000 Veterans in the projected facility Registry range, in increments of 1,000. A planner developing a space program for a project with a requirement above or below this range shall use these standards as a baseline and manually adjust the Program for Design with support of the Office of Construction and Facilities Management (CFM).

V. Functional Areas and rooms / spaces are developed following the Patient Aligned Care Teams (PACT) patient care delivery model for Community Based Outpatient Clinics defined by the Veterans Health Administration (VHA) at the Department of Veterans Affairs.

W. Patient Aligned Care Team (PACT) is the VHA branded evolution of the Patient Centered Medical Home (PCMH) and has been implemented in all VHA health care facilities. PACT is a patient-driven, team-based approach that delivers efficient, comprehensive, and continuous care through active communication and coordination of healthcare services.

PACT is based on a set of seven principles and depends on a core and extended team of healthcare personnel who work with the Veteran patient to plan for their overall health.

This model is focused on all patients receiving VA Primary Care, which is known to be 80 to 90% of the enrolled Veteran patient population. The seven principles of the VHA PACT are:

1. Patient-driven care,

2. Team-based care giver collaboration,

3. Enhanced efficiency,

4. Comprehensive health and wellness services,

5. Continuous patient-provider relationship,

6. Improved communication,

7. Interdisciplinary, seamless service coordination.

X. Interdisciplinary Program Behavioral Health Team-Based Care (BHIP) has evolved along with PACT as a team of mental health professionals working together to focus on the Veteran’s mental health and well-being in a collaborative, Veteran centered and coordinated team-based care model. Six principles of VHA BHIP are to promote:

1. Proactive, integrated, comprehensive mental health care,

2. Increased Veteran access to mental health care,

3. Veteran-centered, recovery-oriented, evidence-based care,

4. Improved coordination and continuity of care,

5. Improved overall Veteran health status,

6. Increased care giver collaboration.

Y. Spaces provided in a CBOC are organized in four Functional Zones:

1. Veteran Welcome Zone: Rooms and spaces associated with the Veterans’ arrival, reception, check-in, comfort, camaraderie, and ease of wayfinding and smooth transitions between steps in care. Provides arrival to and the transition of a largely open and interconnected set of spaces likened to a small town main street or the atrium in a shopping mall. Providing visual connectedness and access to the waypoints in the Veterans care in the clinic. The intent is to create a warm personal welcome, rapid check-in via assisted kiosk use, and a rapid comfortable transition between steps in care. The following Functional Areas are located in this Zone:

a. FA1: Outdoor Public Area

b. FA2: Indoor Public Area

c. FA3: Veteran Welcome Area

d. FA4: Cafe / Refreshment Area

2. Veteran Service Zone: The functional zone contains rooms and spaces associated commonly with diagnostic, therapeutic, and dispensing service provision in the outpatient setting. While certain spaces in this zone may be integrated into the clinical neighborhoods in project specific design situations, they are generally thought of like store fronts lining the main circulation pathway of the Veteran Welcome Zone allowing easy access to these services. The following Functional Areas are located in this Zone:

a. FA5: Veteran Education / Group Area

b. FA6: Physical Medicine, Prosthetics & Orthotics Area

c. FA7: Laboratory Medicine Area

d. FA8: Imaging Area

3. Clinical Neighborhood Zone: The functional zone containing rooms and spaces commonly associated with the provision of one-on-one clinical care by a maximum variety of integrated clinical teams. A base clinic planning unit … made up of on-stage patient care rooms and off-stage teamwork spaces at a minimum. Some veteran Services Functions may be integrated on a project by project basis. The following Functional Areas are located in this Zone:

a. FA9: Patient Care Area

b. FA10: Teamwork Area

4. Operational Support Zone: The functional zone containing rooms and spaces commonly associated with the non-direct patient care operational management and supportive functions that support clinical care delivery. The following Functional Areas are located in this Zone:

a. FA11: Logistics Area

b. FA12: Police Area

c. FA13: Management Area

d. FA14: Staff Wellness Area

e. FA15: Mobile Technology Area

Z. Functional Area description:

1. FA1: Outdoor Public Area: A group of spaces supporting ease of access to the clinic, weather protection for those arriving and leaving the clinic, and other exterior amenities.

2. FA2: Indoor Public Area: A set of spaces providing for weather protected entry, convenient placement of mobility aids, and hand sanitization and masks for those with cold symptoms.

3. FA3: Veteran Welcome Area: A group of spaces supporting a warm personal welcome, rapid assisted self-check-in, ease of wayfinding, relaxation between steps in care, and comfort facilities. Spaces are composed to provide a core circulation area linking steps in care.

4. FA4: Cafe / Refreshment Area: A set of spaces established to enhance the comfort of our guests and to often serve as a de facto social hub for Veterans using the clinic.

Refreshments in smaller clinics may be provided by volunteers, while larger clinics may support a formal cafe’ or coffee shop.

5. FA5: Veteran Education / Group Area: A group of multipurpose rooms and spaces to support group care, education events, and meetings. Almost all meeting spaces in the clinic should be placed to allow direct access from the Veteran Welcome Zone to support easy use by veterans.

6. FA6: A set of spaces integrating physical therapy, prosthetics, and certain whole health services associated with direct hands on therapies and the dispensing of assistive devices and related items directly to the Veteran.

7. FA7: A group of spaces associated with the acquisition and processing of physical specimens for diagnostic testing. Will usually be accessed directly from the Veteran Welcome Area.

8. FA8: A set of spaces aligned with acquiring and processing diagnostic images in support of clinical diagnosis, treatment planning and follow-up. Will usually be accessed directly from the Veteran Welcome Area.

9. FA9: A group of rooms and spaces serving the face-to-face care needs of the Veterans consisting of height and weight stations, universal patient care rooms set-up to meet specific care needs, and patient toilets.

10. FA10: A set of spaces providing workstations for staff and places for equipment, supplies, and medication for use at the point of use. The heart of the clinical neighborhood.

11. FA11: A group of spaces supporting materials handling and storage needs, as well at communications and data rooms, usually located in the back of the clinic in off-stage out of flow areas

12. FA12: A set of rooms supporting security operations in the clinic. Usually set up as suite of connected rooms.

13. FA13: A group of rooms and spaces supporting team-based leadership in the CBOC.

Shared administrative offices form the foundation of this functional area. Additional rooms are added as the clinic grows reflecting an enlarging leadership team.

14. FA14: A set of rooms and spaces that support staff wellness, recharging, comfort, and rest needs. These shared spaces are often multipurpose with many overlapping uses, such as the multipurpose/break room which may be used for breaks, meals, huddles, and quiet work at various times.

15. FA15: A group of elements supporting mobile services needs such as mobile MRI

4 INPUT DATA STATEMENTS (IDS)

A. How many enrolled Veterans are projected to get healthcare services in this Clinic? (W) (Values: 850 to 30,000) (Default: 850)

5 SPACE PLANNING CRITERIA

A. FA 1: OUTDOOR PUBLIC AREA

1. CBOC Veteran Drop-off, Bldg Sprt (SB101) ...................................... 0 NSF (0.0 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 20,000

b. Provide 2 if [projected Veteran enrollees] is between 20,001 and 30,000

A covered portico sheltering drop-off and entry from the weather with adequate clearance to allow two vehicles to easily pass. Provide adequate buffer at entry so people awaiting pick-up do not trigger automatic doors.

2. CBOC Valet Parking Station, Bldg Sprt (SB102) ................................ 0 NSF (0.0 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 30,000

3. CBOC Bicycle Rack Area, Bldg Sprt (SB103) ...................................... 0 NSF (0.0 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 20,000

b. Provide 2 if [projected Veteran enrollees] is between 20,001 and 30,000

4. CBOC Service Dog Walk Area, Bldg Sprt (SB104) .............................. 0 NSF (0.0 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 30,000

B. FA 2: INDOOR PUBLIC AREA

1. CBOC Vestibule / Indoor Buffer, Bldg Sprt (SB291) .....................120 NSF (11.2 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 6,000

b. Provide 1 at 200 NSF if [projected Veteran enrollees] is between 6,001 and

20,000

c. Provide 1 at 260 NSF if [projected Veteran enrollees] is between 20,001 and

30,000

A vestibule with a right angle turn is preferred due to superior weather exclusion.

Provide adequate buffer at entry so people circulating in the welcome area do not trigger automatic doors.

2. CBOC Wheelchair Corral / Parking, Clncl Sprt (SB262) ................... 30 NSF (2.8 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 2,001 and 20,000

b. Provide 2 if [projected Veteran enrollees] is between 20,001 and 30,000

An actual corral structure is preferred. Avoid design solutions with loose wheelchairs at entry and/or in vestibule.

3. CBOC Mobile Lift Corral / Parking, Clncl Sprt (SC093) .................... 40 NSF (3.8 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 2,001 and 20,000

b. Provide 2 if [projected Veteran enrollees] is between 20,001 and 30,000

A small clinic may have a single lift shared across the clinic placed close to the teamwork area. In clinics large enough to support a dedicated lift serving the welcome area, the lift should be placed convenient to the entry, but not exposed or subject to entanglement with wheelchairs.

4. CBOC Gurney Corral / Parking, Clncl Sprt (SB253).......................... 30 NSF (2.8 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 2,001 and 20,000

b. Provide 2 if [projected Veteran enrollees] is between 20,001 and 30,000

A small clinic may have a single gurney shared across the clinic placed close to the teamwork area. Gurneys are rarely used and are subject to soiling if kept in a high traffic area. In clinics large enough to support a dedicated gurney serving the welcome area, the gurney should be placed convenient to the entry, but not exposed to soiling

5. CBOC Public Health Kiosk, Clncl Sprt (SC170) ................................. 20 NSF (1.9 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 8,000

b. Provide 2 if [projected Veteran enrollees] is between 8,001 and 16,000

c. Provide 3 if [projected Veteran enrollees] is between 16,001 and 23,000

d. Provide 4 if [projected Veteran enrollees] is between 23,001 and 30,000

A kiosk used to provide gloves, masks, and hand sanitizer.

C. FA 3: VETERAN WELCOME AREA / MAIN STREET

1. CBOC Assisted Veteran Electronic Check-in, Clncl Sprt (SC165) ...... 35 NSF (3.3 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 2,000

b. Provide 2 if [projected Veteran enrollees] is between 2,001 and 6,000

c. Provide 3 if [projected Veteran enrollees] is between 6,001 and 10,000

d. Provide 4 if [projected Veteran enrollees] is between 10,001 and 14,000

e. Provide 5 if [projected Veteran enrollees] is between 14,001 and 18,000

f. Provide 6 if [projected Veteran enrollees] is between 18,001 and 22,000

g. Provide 7 if [projected Veteran enrollees] is between 22,001 and 26,000

h. Provide 8 if [projected Veteran enrollees] is between 26,001 and 30,000

Provides space for staff assisted kiosk use by Veterans and functionally replaces the check-in “desk” or “window.” Place kiosks prominently near the entry and in larger clinics at key circulation points aligned with anticipated circulation patterns and staffing workflows.

2. CBOC Welcome Station, Clncl Sprt (SC005) .................................. 100 NSF (9.3 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 6,000

b. Provide 1 at 150 NSF if [projected Veteran enrollees] is between 6,001 and

14,000

c. Provide 1 at 200 NSF if [projected Veteran enrollees] is between 14,001 and

22,000

d. Provide 1 at 250 NSF if [projected Veteran enrollees] is between 22,001 and

30,000

A place for staff and volunteers to welcome arriving guests, guide Veterans to next steps in care, and provide information. Most often an open “information desk” like element. Should be open and inviting. While its primary function is like an “information desk”, there may be sharing of information adequate to direct the Veteran to the next step in care and as such functions to a degree like a “check-in desk.” Therefore, it is important to allow adequate clearances and circulation space to aid privacy.

3. Interview Patient Care Room, CBOC (OCB11) .............................140 NSF (13.1 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 6,000

b. Provide 2 if [projected Veteran enrollees] is between 6,001 and 14,000

c. Provide 3 if [projected Veteran enrollees] is between 14,001 and 22,000

d. Provide 4 if [projected Veteran enrollees] is between 22,001 and 30,000

While assisted kiosk use by Veterans can handle upwards of 98% of check-in needs, Veterans and staff need a space to discuss complex needs, update detailed data as in “means testing”, take photos for ID cards, and other issues. An interview room convenient to the welcome area can meet these and other needs. The interview room is a form of patient care room focused on brief dialogue with the Veteran and that may contain special items such as a camera for ID pictures. It may be used by clinical staff from time to time to interview and triage a Veteran with an immediate need. All patient care rooms should have a sink.

4. CBOC Veteran Appreciation Area, Bldg Sprt (SB105) ..................... 30 NSF (2.8 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 6,000

b. Provide 1 at 100 NSF if [projected Veteran enrollees] is between 6,001 and

14,000

c. Provide 1 at 150 NSF if [projected Veteran enrollees] is between 14,001 and

22,000

d. Provide 1 at 200 NSF if [projected Veteran enrollees] is between 22,001 and

30,000

The sole purpose of a VHA clinic is to serve our Veterans. It is important we make that purpose clear to our Veterans and our staff. A prominent element of our clinics and especially the welcome area should be displays of our respect. The veteran appreciation area is often a wall with a locally inspired and created display honoring our Veterans, service to the country, and/or describing that history of service. Many approaches are possible.

5. CBOC Veteran Information Station, Bldg Sprt (SB133) ................... 10 NSF (1.0 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 10,000

b. Provide 2 if [projected Veteran enrollees] is between 10,001 and 18,000

c. Provide 3 if [projected Veteran enrollees] is between 18,001 and 26,000

d. Provide 4 if [projected Veteran enrollees] is between 26,001 and 30,000

The Veteran Information Station is intended as a guide to veterans in the use of the clinic. It can take many forms from a simple floor plan graphic of the clinic used to locate a destination to a touch screen interactive display.

6. CBOC Veteran Video Connect Station, Clncl Sprt (SC274) .............. 80 NSF (7.5 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 2,000

b. Provide 2 if [projected Veteran enrollees] is between 2,001 and 6,000

c. Provide 3 if [projected Veteran enrollees] is between 6,001 and 10,000

d. Provide 4 if [projected Veteran enrollees] is between 10,001 and 14,000

e. Provide 5 if [projected Veteran enrollees] is between 14,001 and 18,000

f. Provide 6 if [projected Veteran enrollees] is between 18,001 and 22,000

g. Provide 7 if [projected Veteran enrollees] is between 22,001 and 26,000

h. Provide 8 if [projected Veteran enrollees] is between 26,001 and 30,000

Veteran Video Connect Station is a prefabricated booth, a room, or a private cubicle provided for Veteran use in conducting a private video based visit with VA staff at another location. Distinct from a full telehealth room with diagnostic sets and high resolution cameras, these spaces are intended for less formal interactions. Examples may include discussion with a prosthetics clerk, completing means testing with a business office staff member, requesting release of records, or talking to a patient advocate.

7. CBOC Veteran / Guest Seating, Bldg Sprt (SB003) .......................260 NSF (24.2 NSM)

a. Provide 1 if [projected Veteran enrollees] is between 850 and 1,000

b. Provide 1 at 330 NSF if [projected Veteran enrollees] is between 1,001 and 2,000

c.…