Attachment D.13 - PACT Space Module Design Guide.pdf

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O�ce of Construction & Facilities Management design

JUNE 2015

PACT Space Module

Attachment D.13 - PACT Space Module Design Guide

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PACT Space Module Design Guide 2015 i

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

Page Number

TABLE OF CONTENTS

1.0 EXECUTIVE SUMMARY

1.1 PACT Module Design Standards 1

2.0 INTRODUCTION

2.1 Design Guide Introduction

2.2 Introduction to VHA PACT for Primary Care

2.3 Introduction to the Guiding Principles of the PACT Approach

3.0 THE PATIENT EXPERIENCE

3.1 PACT Functional Goals

3.2 PACT Process

4.0 PLANNING AND DESIGN

4.1 Clinic Organization

4.2 PACT Space Module Core Design Strategies

4.2.1 Collaborative Work Environment

4.2.2 Separation of Patient and Staff Flows

4.2.3 Modular, Adaptable Design

4.3 PACT Space Module Core Components

4.3.1 Core Components

4.3.2 PACT Space Module Dimensions

4.3.3 Patient Corridor

4.3.4 Patient Care Room

4.3.4A Exam Room 4.3.4B Consultation Room 4.3.4C Procedure Rooms

Table of Contents Index of Figures Acknowledgements Foreword i iii vi ix ii

7.1 The Lean Design Process

7.0 APPENDIX

4.0 PLANNING AND DESIGN (Continued)

4.3 PACT Space Module Core Components (Continued)

4.3.5 Group Care Rooms

4.3.6 Teamwork Zone

4.3.7 Core Supplies

4.3.8 Teamwork Support Zone

4.4 PACT Module Support Components

4.5 Approach to Renovation

5.0 SPECIAL CONSIDERATIONS

5.1 Interiors and Finishes

5.1.1 Interior Finishes: Color, Texture, and Pattern

5.1.2 Wayfinding

5.1.3 Sliding Door Hardware

5.1.4 Security and Safety

5.1.5 Patient Care Room Modular Casework

5.1.6 Furniture Systems and Equipment

5.1.7 Wall Systems

5.1.8 Daylight and Artificial Lighting

5.1.9 Acoustics, Noise Control

5.1.10 Evolving Technology

6.0 CASE STUDIES AND BENCHMARKS

6.1 Case Study - VA/DOD Monterey

6.2 Case Study - VA Stockton

6.3 Case Study - VA San Jose

6.4 Benchmark - Group Health Puyallup Medical Center

6.5 Benchmark - University of Utah Healthcare - South Jordan Health Center

Page Number

TABLE OF CONTENTS

iii

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

TABLE OF FIGURES

Figure 2.1-1 PACT Integrated Teams Figure 2.2-1 Patient Aligned Care Team Rendering Figure 2.2-2 The Patient’s Primary Care Team Figure 2.2-3 PACT Access and Care Delivery Diagram Figure 2.2-4 PACT Appointment Trends

Figure 3.1-1 PACT Principle and Operational Goal Matrix Figure 3.2-1 Online Scheduling/ My HealtheVet Online/ Online Secure Messaging Figure 3.2-2 Face-to-Face Clinic Visit/ Shared Medical Appointment/ Telehealth Appointment Figure 3.2-3 Clear Point of Entry/ Patient Greeting and Assistance/ Corridors and Connections Figure 3.2-4 Visual Control/ Bring Services to the Veteran/ Standard Work Figure 3.2-5 Patient-Centric Care Room/ Equipment and Supplies at Point-of-Use/ Diagnostic Services Figure 3.2-6 Follow-Up Planning/ Provider Summary and Instructions/ In-Room Printing

Figure 4.1-1 PACT Space Module Design Diagram Figure 4.1-2 PACT Prototype Design Diagram Figure 4.1-3 Legacy Clinic Patient Flow Figure 4.1-4 Integrated PACT Clinic Patient Flow Figure 4.1-5 Integrated Clinic Utilizing PACT Modules Figure 4.2-1 Three Core Design Strategies for PACT Figure 4.2-2 4-5 Teamlets per PACT Module Figure 4.2-3 Touchdown Zones for PACT Teamlets and Extended Care Team Members Figure 4.2-4 Photo of a Patient Corridor Figure 4.2-5 Three Flows in the Dual Corridor System Figure 4.2-6 Separation of Patient and Staff Flows Figure 4.2-7 Patient Corridor Rendering Figure 4.2-8 Relationship Between Exam/Consult and Procedure Room Units Figure 4.2-9 Adaptability of the Universal Room Figure 4.2-10 Multiple Departments in an Integrated Clinic Figure 4.3-1 PACT Space Module Diagram with Core Components Figure 4.3-2 PACT Space Module Dimensions Figure 4.3-3 Patient Corridor PACT Space Module Layout Figure 4.3-4 Photo of a Patient Corridor Figure 4.3-5 Patient Care Room PACT Space Module Layout Figure 4.3-6 Exam Room PACT Space Module Layout Figure 4.3-7 Photo of a Typical Exam Room Figure 4.3-8 Photo of a Typical Exam Room Figure 4.3-9 Example of a Exam Room Floor Plan Figure 4.3-10 Consultation Room PACT Space Module Layout iv

Figure 4.3-11 Consultation Room Rendering Figure 4.3-12 Example of a Consultation Room Floor Plan Located in Module Figure 4.3-13 Procedure Room PACT Space Module Layout Figure 4.3-14 Example of a Procedure Room Floor Plan Figure 4.3-15 Group Care Room PACT Space Module Layout Figure 4.3-16 Photo of a Group Care Room Figure 4.3-17 Photo of a Group Care Room Figure 4.3-18 Example of a Group Care Room Floor Plan Figure 4.3-19 Teamwork Zone PACT Space Module Layout Figure 4.3-20 Photo of Teamwork Zone Daylighting Figure 4.3-21 Photo of Teamwork Zone Daylighting Figure 4.3-22 Views and Daylight for Staff Spaces Figure 4.3-23 Teamwork Zone Rendering Figure 4.3-24 Core Supplies PACT Space Module Layout Figure 4.3-25 Photo of a Medication Room Figure 4.3-26 Photo of Core Supplies Figure 4.3-27 Enlarged Floor Plan of Core Supplies Figure 4.3-28 Teamwork Support Zone PACT Space Module Layout Figure 4.3-29 Photo of a Teamwork Support Zone Figure 4.3-30 Example of a Teamwork Support Zone Figure 4.4-1 Reception/Greeting/Check-in Kiosk Rendering Figure 4.4-2 Reception/Greeting/Check-in Options Figure 4.4-3 Example of a Main Lobby/Waiting Figure 4.4-4 Example of a Main Lobby/Waiting Figure 4.4-5 Photo of an Accessible Height/Weight station Figure 4.4-6 Women’s Health Exam - Two Room Option Figure 4.5-1 Diagram of Renovation Priorities

Figure 5.1-1 Photo of Entrance Portal Figure 5.1-2 Photo of Sliding Door Figure 5.1-3 Photo of Sliding Door Figure 5.1-4 Example of Sliding Door Details Figure 5.1-5 Photo of One-way Glass from Teamwork Zone to Patient Transition Area Figure 5.1-6 Example of Modular Casework with Mobile Cart Storage Figure 5.1-7 Photo of Public Waiting Figure 5.1-8 Example of Modular Wall System Figure 5.1-9 Photo of Daylighting Figure 5.1-10 Absorbent Materials Figure 5.1-11 Sound-Proofed Wall and Door System

TABLE OF FIGURES

v

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

Figure 6.1-1 VA Monterey Pre-PACT Figure 6.1-2 VA Monterey Floor Plan Figure 6.2-1 VA Stockton Pre-PACT Figure 6.2-2 VA Stockton PACT Test Fit Figure 6.3-1 VA San Jose PACT Test Fit Figure 6.4-1 Group Health Puyallup Medical Center Axon Figure 6.4-2 Group Health Puyallup Medical Center Floor Plan Figure 6.5-1 University of Utah Healthcare - South Jordan Health Center Floor Plan

Figure 7.1-1 Lean Workshop Figure 7.1-2 Flow Diagram Exercise Figure 7.1-3 Example of “7 Designs” Figure 7.1-4 Flow Diagram Photo

TABLE OF FIGURES

vi

ACKNOWLEDGEMENTS

The following individuals are those who have made the PACT Space Module Design Guide possible through their guidance, insight, advice, and expertise:

Department of Veterans Affairs Gordon Schectman, MD Chief Consultant for Primary Care Services

Richard Stark, MD Executive Director, Primary Care Operations

Joanne Shear Clinical Program Manager, Primary Care Operations

W. Ward Newcomb, MD, MMM Consultant for PACT Functional Space Design, Primary Care Services

Kathryn Corrigan, MD National Primary Care Lead for Telehealth, Primary Care Services

Ryan Mancari Health System Specialist, Office of Primary Care Services

Angela Denietolis, MD Associate Chief of Staff for Ambulatory Care, James A.

Haley Veteran’s Hospital

Anne E. Emler, MD Associate Chief of Medicine VA NWIHCS – Lincoln

Kathleen M. Wolner, MD Medical Director Charlotte CBOC - SBYVAMC

Andrea Fair Assistant Team Lead, Construction Team 1

Palo Alto Healthcare System Jason Nietupski Chief, Office of Facility Planning and Development

Bill McGurk, PE Chief, Major Projects Team

Brad Wildridge, RA Project Manager, Major Projects Team COR, Design Guide

Jim Romer, RA Medical Equipment Planner, Major Projects Team

VA-Office of Construction & Facilities Management Stella S. Fiotes, AIA Executive Director

Lloyd H. Siegel, FAIA Associate Executive Director, Office of Facilities Planning

Donald L. Myers, AIA Director, Facilities Standards Service

Gary Fischer, AIA Senior Healthcare Architect, Facilities Standards Service

Linda Chan, AIA Facilities Planner, Facility Planning Development Service vii

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

ACKNOWLEDGEMENTS

Cannon Design Mark Herman, LEED AP BD+C Principal

Jennifer Ries Associate Vice President

Rachel Bickel Associate

Leslie McCanne Technical Support

Brandon Kent, LEED AP BD+C Associate

Jennifer Marckx Technical Support

Wonkyung Kim, AIA, LEED AP Associate

Arlene Sanchez, EDAC Technical Support

MEI Architects Mei Mei Chan, AIA Principal

Donald Luu Principal

Sean Matthews Project Manager

Ian Tomitch Technical Support

CollinsWoerman Architects Doug Grove, RA Lean Consultant ix

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

FOREWORD

The PACT (Patient Aligned Care Team) Space Module Design Guide (2015) represents a significant change in VA’s approach to the environment of care for the delivery of Primary Care Services to our Nation’s Veterans. VA’s transformation of care to PACT, a Veteran-centric, medical home model of care, required a new space planning and design paradigm. The PACT Space Module Design Guide is an extremely important addition to the series of Design Guides produced by the Office of Construction and Facilities Management (CFM) in support of the planning and design of healthcare facilities for the United States Department of Veterans Affairs.

This Design Guide formalizes conceptual planning and design information that has been gathered during the past three years through extensive collaboration, among VHA Central Office, VISN Leadership, and CFM, augmented with countless hours of meeting and consultation with clinical staff and frontline leadership in the field. This effort was also supplemented with lengthy interaction with private sector healthcare providers and site tours of their facilities. Those providers have undergone a similar transformation and have implemented facility solutions to support their version of the medical home care delivery model.

This Design Guide was developed under the guidance of W. Ward Newcomb, MD, MMM and Gary Fischer, AIA with support from Major Projects Staff at the VA Palo Alto Healthcare System and the consulting services of MEI and CannonDesign. It’s success and excellence is attributed to the extensive development and input provided by the individuals listed in the Acknowledgement Section of this Design Guide. Staff from Primary Care Services and CFM worked together closely to lay the foundation for this Design Guide. This effort included literature reviews, strategic workgroups and meetings, engagement of key stakeholders, and multiple site visits to facilities demonstrating space redesign innovations. During this extensive process, the essential connection between function and form was continually highlighted, and lean processes identified to optimize the potential for space design to enable the health care team to provide outstanding clinical care. This ongoing CFM/Primary Care journey of collaboration and teamwork will facilitate continuous development and innovation of PACT space as it is fully adapted to meet the clinical needs of our Veterans.

This Design Guide is the standard for the development of PACT – Primary Care space within all VA facilities. It contains planning and design concepts that support the patient centered care delivered and illustrates concepts for creating functional, efficient, nurturing, pleasing, and adaptable environments for our Nation’s Veterans, as well as those who serve and honor the Veteran patients.

These concepts illustrate facility planning possibilities, allowing room for adjustments as necessary, to facilitate incorporation of the needs of each specific clinic location. The utilization of a consistent PACT Clinical Space Module for planning and design of all VA facilities in which Primary Care services are provided will contribute significantly to an environment of standard effective and efficient care. Those who have served the Nation will utilize these facilities more than any other VA facility for the remainder of their lives, and they deserve no less.

Lloyd H. Siegel, FAIA Gordon Schectman, MD

1.0 EXECUTIVE SUMMARY

PACT SPACE MODULE

P A T I E N T A L I G N E D C A R E T E A M

Facilities Management

1.0 EXECUTIVE SUMMARY1.0 EXECUTIVE SUMMARY1.0 EXECUTIVE SUMMARY

Background:

In 2009, the Department of Veterans Affairs (VA) Universal Services Task Force Report, “Veterans Health Care: Leading the Way to Excellence,” recommended formal adoption of a team-based model of care. To apply this recommendation within Primary Care, the Veterans Health Administration (VHA) adopted the patient-centered medical home model of care and then customized and branded a VA version of the patient-centered medical home model as the Patient Aligned Care Team (PACT). In late 2010, VHA and the Office of Construction and Facilities Management (CFM) combined resources to begin the process of defining and developing space requirements and standards to support the new care delivery paradigm, while at the same time VHA continued to develop and fine-tune the operational components of PACT.

After extensive, on-going collaboration between a VHA/ CFM Core Team, and Veterans Integrated Service Network (VISNs) facilities across the VA enterprise, it was determined that a formalized Space Design Standard document was needed for use across the system. This PACT Space Module Design Guide is the result of this effort.

PACT Space Module Design Guide:

This PACT Space Module Design Guide is an initial document illustrating the planning and design standards that have been identified and developed by VHA and CFM.

As PACT represents a cultural transformation to a ‘patient-centered – team based’ model for the enhanced delivery of Primary Care Services to veterans, the VA planning and design standards for Primary Care also required transformation to support the new care delivery paradigm.

PACT as a care delivery model will evolve over time;

likewise, the planning and design standards to support PACT will evolve as well. Thus this version of the PACT Space Module Design Guide is envisioned as an initial standard that will also evolve as necessary to provide the most current direction to planners, designers, and VA clinicians who are involved with project planning and design in the field.

PACT Space Planning and Design Guiding Principles:

During the course of the development of these space planning and design standards, facilities around the country were identified as models of care sites. Site visits were conducted with numerous VA/VHA staff and architectural and engineering (A/E) consultants attending. Where site visits were not conducted, facility floor plans and other anecdotal information has been gathered. Direct face-to-face and virtual meetings also were held in over 15 VISNs and dozens of Medical Centers. Through these visits, extensive input, as well as an understanding of operations, space issues, and opportunities specific to applying PACT were gathered.

Based on these combined experiences, the following design objectives for PACT space planning and design were developed based on VHA’s guiding principles of providing Patient-Centered Care, Coordination of Care, and Access to Care:

I. Design objectives focused on Patient-Centered

Care:

A. Create a calm, healing environment.

B. Reduce waiting and wasteful or redundant actions and activities.

C. Focus on adding value to the veteran:

— Facilitate processes that allow veterans to be seen when they want to be seen.

— Increase caregiver face-to-face time with veteran.

— Right-size patient care areas to facilitate “rooming the veteran” and reduce waiting.

— Convert excess waiting room space to value-added space such as patient care rooms, group care rooms, teamwork space, and patient education space.

1.1 PACT Space Module Design Standards

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

1.0 EXECUTIVE SUMMARY

1.1 PACT Space Module Design Standards

— Provide the appropriate number of examination rooms to accommodate volume of veterans based on a time analysis of integrated primary care visits.

D. Room the veteran with family member/caregiver participation in mind:

— Create a ‘right-sized’ examination room to accommodate family members/caregivers that accompany the veteran.

— Ensure examination rooms are large enough to accommodate scooters and larger wheelchairs.

E. Create a veteran-centered “one stop shop” approach:

— Collocate team members and services.

— Bring services to the veteran in the examination room.

— Provide flexible/adaptable space to support a variety of care modalities.

F. Create a balanced approach to care delivery tailored to the veteran’s level of need:

— Telephone/Virtual Care including telehealth modalities.

— Shared Medical Appointments (SMAs), group care, and peer-to-peer support.

— E-consultation and real-time provider-to-provider consultation.

— Face-to-face care.

II. Design objectives focused on Team-Based Care:

A. Collocate staff caring for a population of veterans in the outpatient setting:

— Support direct staff communication/consultation and face-to-face hand-offs.

— Promote collegiality.

B. Create team-based office work space:

— Ensure logical and efficient flow between exam rooms and care team work settings.

— Ensure direct visual connection among staff.

— Accommodate quiet and engaging workspace supported by IT/communications technologies.

— Provide for a range of work spaces, which can support team-based work, huddles, and quiet/solo activities.

C. Enhance work flow:

— Separate on-stage from off-stage work (Dual corridor model recommended).

— Collocate staff to enhance real time decision making

— Allow immediate access to quick turnover supplies and equipment.

D. Enhance privacy through space planning:

— Reduce foot/equipment/cart traffic in patient care areas.

— Control access to patient care areas and team work areas.

— Establish zones/hierarchy of use to improve privacy.

III. Design Objectives focused on Access to Care:

A. Standardize room designs:

— Create universal exam/consult rooms.

— Create universal procedure rooms.

— Design all patient care rooms to support virtual care/telehealth capabilities.

B. Provide space for Shared Medical Appointment group care and/or group education, with telehealth capability.

C. Support a modular approach to overall clinic design and space planning:

— Standardized adaptable modular planning:

1. Universal/base clinical care module.

2. Adaptable to other services; i.e., laboratory, radiology, eye clinic, etc.

3. Adaptable to future re-tasking of space with minimal construction.

1.0 EXECUTIVE SUMMARY

1.1 PACT Space Module Design Standards

D. Develop a space/planning grid that minimizes intrusions into clinical space by the structural framing grid (columns and bracing) and location of building utility spaces (HVAC, electrical IT/communications).

Team Accomplishments:

Using these principles the VHA/CFM Team was invited to assist in conveying these principles and concepts on several million square feet of outpatient VHA clinical infrastructure. The team has gained insight into the needs of PACT teams, which favor clinical integration, team care, collocation of staff, and the one-stop-shop approach to care delivery. Most recent design and construction projects have increasingly adopted many of these recommendations as design experience has been gained.

Next Steps:

• Create a multidisciplinary team which includes, but is not limited to: PACT, Mental Health, Specialty Care, Women Veterans Care, and other Facility and Design Subject Matter Experts (SME).

• Broaden direct PACT field consultation activities to promote information exchange.

• Form a broad-based education program for leadership, VISNs, local facilities, and front-line clinical staff to include on-site and virtual facility tours, standardized presentations, and virtual university seminars. Develop a practical manual that will focus on clinical operations and facility interface.

2.0 INTRODUCTION

PACT SPACE MODULE P A T I E N T A L I G N E D C A R E T E A M

2.0 INTRODUCTION

2.1 Design Guide Introduction

Recognizing the need for a highly-developed, efficient, and integrated health care system, the Veterans Health Administration (VHA) authorized a team-based primary care model in 1994 emphasizing provision of care that is accessible, timely, coordinated, continuous, comprehensive, and compassionate. This transformed VHA from a health care delivery system that revolved around the hospital to one with primary care as the foundation of health care delivery.

In early 2009, the Department of Veterans Affairs Universal Services Task Force report “Veterans Health Care: Leading the Way to Excellence,” recommended the formal adoption of a team-based model of care featuring three major principles:

patient-centered care, coordination of care, and access to care. To apply these principles more completely within Primary Care, VHA adopted and customized the patient-centered medical home model of care and branded VHA’s patient-centered care model as the Patient Aligned Care Team (PACT). The PACT care model is based on a team of health care professionals that provides comprehensive primary care in partnership with the veteran (and the veteran’s personal support person(s)) and manages and coordinates comprehensive health care services consistent with agreed upon goals of care (Figure 2.1-1).

The major roll-out of PACT occurred in 2010. Since that time, the VHA and Office of Construction and Facilities Management (CFM) have been investigating how the planning and design of primary care clinical space will best accommodate and support PACT. Analysis of the practices from the private health care sector and extensive development within VHA has resulted in the PACT Clinical Space Module (“PACT Space Module”) - a single planning unit that contains the components and facilitates the operational flows needed to support PACT.

This guide provides a brief overview of PACT (Section 2), an introduction to how PACT is operationalized (Section 3), and guidelines for the translation of PACT Operations into the PACT Space Module (Section 4). Technical considerations (Section 5) and case study examples (Section 6) are also included.

Resident

TEAMLET

PATIENT

Clerk

PC Provider Clinical

Associate

RN Care Manager

Figure 2.1-1 PACT Integrated Teams

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

2.0 INTRODUCTION

2.2 Introduction to VHA Patient Aligned Care Team for Primary Care

The VA health care system and VHA are committed to providing the highest levels of health care to the nation’s Veterans by being patient-centered, team-based, data driven, evidence-based, and continuously improving. PACT is a patient-driven, team-based model of care that responds to this commitment. Care is delivered by integrated teams, called Patient Aligned Care Teams (PACT) (Figure 2.2-1).

The goals of PACT Primary Care teams are to improve the veteran experience, clinical quality, safety, and efficiency by ensuring that VHA is delivering the highest level of health care possible.

Figure 2.2-1 Patient Aligned Care Team Rendering

2.0 INTRODUCTION

2.2 Introduction to VHA Patient Aligned Care Team for Primary Care

Other Team Members

Teamlet

Patient

Other Team Members Clinical Pharmacy Specialist Clinical Pharmacy Anticoagulation Social Worker Nutritionist Care Managers Trainees Integrated Behaviorial Health Psychologist Psychiatrist

Teamlet

Assigned to 1 panel

Panel size adjusted (modeled) based on staffing, acuity, etc.

Panel size monitored via Primary Care Utilization Data:

Provider RN Care Manager Clinical Associate (LPN, MA, or Health Tech) Administrative Associate

The Patient’s Primary Care Team

Figure 2.2-2 The Patient’s Primary Care Team

PACT, as a care model, is a partnership between the veteran and the health care team with an emphasis on prevention, health promotion, and self-management. PACT uses an engaged, collaborative team-based approach, with various members of the team stepping in at different points in time to provide needed care. Veterans are the center of the care team that also includes family members, caregivers, and health care professionals. The four person teamlet is the basic functional unit of PACT supporting the veteran.

It is comprised of the Provider, the RN-Care Manager, the Clinical Associate, and the Administrative Associate. When more specialized services are needed, other members such as discipline-specific (i.e., Clinical Pharmacy, Social Work, Nutrition, Behavioral Health, etc.), specialty (i.e., Cardiology, Neurology, etc.), or non-VA team members step in to assist the veteran and teamlet, together making up the PACT Primary Care Team.

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

2.0 INTRODUCTION

2.2 Introduction to VHA Patient Aligned Care Team for Primary Care

In-person, face to face

1:1 or Group Visits

Non-face to face

Telephone, Home Telehealth

Virtual face-to-face

Clinical Video Teleheath

Virtual non-face-to-face

Secure Messaging

Figure 2.2-3 PACT Access and Care Delivery Diagram

The entire PACT Primary Care team is focused on helping the veteran meet his/her health care goals. PACT offers improved ways to access health care. In addition to personal visits with their own primary health care teamlet, veterans may schedule visits with other members of a PACT team or may select group clinic appointments and/or educational classes. To further improve health care access, virtual health care is available to veterans utilizing modalities such as the telephone contacts, secure messaging, or Telehealth technology. Veterans may access a personal health vault, selected portions of their electronic health record, and a wealth of health information using My HealtheVet.

Implementation of PACT represents a practice change.

It is a new paradigm requiring strategic assessment and redeployment of resources, realignment of priorities, and a major cultural change from system-centered to patient-centered care. The successful implementation of PACT also requires a paradigm shift in the physical environment to meet the needs of the integrated, collaborative care team, and the deployment of care delivery modalities (shared medical appointments, Telehealth, and other virtual scenarios) other than the traditional face-to-face visit (Figure 2.2-3).

Improved access and efficiency may be achieved by further increasing virtual and group care across service lines and through further integration of patient care services in the outpatient setting.

Since the roll-out of PACT in 2010 to July 2012, telephone visits with veterans have increased dramatically, use of secured messaging has increased moderately, use of shared medical appointments (SMA) has had limited increase in use, and face-to-face visits have remained relatively stable (Figure 2.2-4).

Figure 2.2-4 PACT Appointment Trends

2.0 INTRODUCTION2.0 INTRODUCTION

Three principles guide the translation of PACT into an operational model (Section 3) and a physical space module (Section 4). These include Patient-Centered Care, Coordination of Care, and Access to Care.

Patient-Centered Care starts with the veteran and focuses on discovering the veteran’s vision of living life fully and helping them fulfill their health goals. The PACT team, including the veteran and personal support persons, come together as partners to create the veteran’s plan for health.

Whether the veteran is fundamentally healthy, or whether the veteran is in the end stages of life, patient-centered care ensures that veterans are offered all of the care they need and PACT staff provide or arrange for care consistent with the veteran’s preferences. To understand those preferences, PACT staff establish a caring longitudinal relationship with veterans and personal support persons that exists beyond a single episode of care. The teamlet is the veteran’s point of contact for his/her health care, meaning one teamlet cares for and coordinates health conditions that occur over time and throughout the health care setting.

Coordination of Care embraces the strong practice of teamwork among members to support highly coordinated care, dedicated to achieving the common goal of excellent, comprehensive primary care for veterans. The synergistic efforts of an effective team surpass the ability of any single individual to meet the health care needs of a panel of veterans. PACT staff employ continuous improvement strategies and active learning to improve the team’s function, increase efficiency, encourage standardization, improve health outcomes, and optimize the quality of care they deliver. Care coordination involves open communication among health care providers, legally permissible exchange of health care information, and logistical integration of desired care encounters.

Access to Care is essential to high quality customer service and supports VHA’s goal to provide prompt and appropriate treatment for veterans’ health concerns. PACT staff, working as a team, will provide the care veterans want and need, when and how they want and need it. In other words, PACT staff work as a team to provide the right care at the right time in the right place by the right person, incorporating the full range of care modalities: face-to-face, group care, and virtual care. Accessible care also requires care to be coordinated, facilitating integration of health care services and navigation through complex health care systems. It involves working across care settings— accessing health care providers and other services such as community programs to help veterans receive the care they need and want without unnecessary duplication of services or avoidable inconveniences.

2.3 Introduction to Guiding Principles of the PACT Approach

3.0 THE PATIENT EXPERIENCE

PACT SPACE MODULE

P A T I E N T A L I G N E D C A R E T E A M

3.0 THE PATIENT EXPERIENCE3.0 THE PATIENT EXPERIENCE

As different clinics have explored the translation of PACT operations into the planning of physical clinic space, seven key functional goals have emerged. These align with the three major principles outlined in Section 2: Patient- Centered care, Team-Based Care, and Accessible Care (Figure 3.1-1). The operational goals include:

Bring Care to the Patient Placing the veteran at the center of the care model has fundamental implications for planning. In the PACT care model, care is provided to the veteran in a singular location wherever possible, with PACT staff doing the majority of the traveling as opposed to having the veteran go to multiple locations to receive care during a single visit.

Support Flexibility and Adaptability Veterans’ care needs and our responding models of care evolve over time. In the PACT care model, care processes need to be able to adapt to meet the future needs and demands of veterans. This is facilitated through physical clinical space that accommodates changes in departments and services.

Provide Privacy and Security Veterans deserve and require privacy and security in all of their interactions with the VA. In the PACT care model, care is provided in a manner that is sensitive to veteran and staff privacy and security concerns.

Streamline Processes With the veteran in the center of the PACT care model waste, redundancy, and delays need to be relentlessly

that eliminates redundancies without dissolving care quality.

Enhance Teamwork Veterans deserve the best care that can be provided through a coordinated care team-based model. In the PACT care model, care is provided in ways that support a team-based approach, providing opportunities for PACT staff to meet for quick huddles, share important information with one another, and optimize veteran hand-offs.

Simplify Wayfinding The veteran experience is enhanced through easy physical access and wayfinding. In the PACT care model, care is provided in ways that support veterans and staff’s ability to quickly orient to their surroundings.

Promote Healing and Well-Being The veteran and staff care experiences are enhanced through creation of calm, quiet, and private clinical spaces.

In the PACT care model, care is enhanced by design features that promote healing and well-being in veterans,

P at ie nt

-C en te re d

Te am

-B as ed

A cc es si bl e

Bring Care to the Patient Support Flexibility and Adaptability Provide Privacy and Security Streamline Processes Enhance Teamwork Simplify Wayfinding Promote Healing and Well-being

Figure 3.1-1 PACT Principle and Operational Goal Matrix

3.1 PACT Functional Goals

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

3.0 THE PATIENT EXPERIENCE

MAKE

APPOINTMENT

TRANSPORT &

ARRIVAL

CONFIRM

APPOINTMENT

PATIENT CHECK-IN

PATIENT ACCESS PATIENT ARRIVAL

Online Scheduling My HealtheVet Online Online Secure Messaging

Appointments:

Multiple access points or channels facilitate faster appointment scheduling, including on-line scheduling and streamlined phone access. Steps required to access the right clinic staff are minimized. In some cases, staff call centers may be utilized to adequately manage call volumes.

The goal is to answer calls and resolve issues in real time.

When volumes are heavy, veterans are given the choice to wait for the next available staff member or to leave a voicemail.

EMR Patient Portal:

In addition to current functionality, “My HealtheVet” may be enhanced to include appointment scheduling, virtual patient visits, and three-way consultations (veteran-PCP-specialty providers). Access to computers and/or Wi-Fi for veteran use in “waiting areas” is becoming common place.

Follow-Up/Reminder Communication:

and secure messaging. Veterans may be encouraged to complete their pre-appointment forms (on-line if possible) and/or asked if they require any further assistance or directions to their appointment.

3.2 PACT Process

Figure 3.2-1

aspect of a veteran’s visit, starting with their initial interaction with the clinic.

3.0 THE PATIENT EXPERIENCE

MAKE

APPOINTMENT

CONFIRM

APPOINTMENT

SHARED MEDICAL

APPOINTMENT

TELEHEALTH

CLINIC VISITPATIENT ACCESS

Face-to-Face Clinic Visit Shared Medical Appointment Telehealth Appointment

Face-to-Face Clinic Visit:

Veterans are most familiar with traditional face-to-face visits.

These visits currently require travel to the clinic for a face-to-face provider/RN/other team member visit. They provide high value, but entail large time investments for both staff and veterans. They are the most space intensive form of routine outpatient primary care.

Shared Medical Appointment:

The shared medical appointment (SMA) is an appropriate option for many care situations, especially those with strong self-management and educational components such as diabetes, congestive heart failure, chronic pain, smoking cessation, weight loss, and dietary education. Some sites also use as a format for minor medical walk-in/drop-in care

- the Drop-In Group Medical Appointment (DIGMA). These appointments add value through peer-to-peer interaction and they are a very efficient form of care delivery from a time and space standpoint. Due to the high volume of veterans that can be served at one time, they also significantly improve access to care. VHA has established a Shared Medical Appointment ‘stop code’ to track SMA workload volume.

Telehealth Virtual Visit:

The use of telephone care, secure messaging, and other forms of virtual care is rapidly expanding across the VA.

Formal telehealth visits use technology to connect a veteran in one location to a provider at another. Multiple specialties can be summoned to remotely provide diagnostic and consultative services for the veteran. In most cases the veteran will travel to a VA Community-Based Outpatient Clinic (CBOC) locally while the provider is at a central site or medical center. Telehealth is gaining use across many service lines such as eye care, geriatrics, mental health, among others. VHA has established a clinical ‘stop code’ for tracking telehealth workload.

Figure 3.2-2

3.2 PACT Process

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

3.0 THE PATIENT EXPERIENCE

MAKE

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TRANSPORT &

ARRIVAL

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PATIENT ACCESS PATIENT ARRIVAL

First Entry:

First impressions and personal contact are made. VA branding elements are incorporated into the entry portal.

Veterans should be able to clearly define wayfinding and sense a calm, quiet and healing environment.

Reception, Greeting, and Check-in:

The Veteran’s first contact with staff is critical to the care experience. The reception area should be designed to support a warm greeting, assisted kiosk check-in, minimize staff and veteran distractions, and support close engagement between staff and veteran. Reception stations should be modular and flexible to meet changing workflows and technology.

Patient Transition Area:

In patient-centered care, reducing time spent waiting by Veterans is a top priority. Fundamental to PACT is “rooming the patient”, and strong adherence to maintaining the schedule grid. These allow the move to smaller seating areas with choices in arrangements and locations for Veterans, caregivers, and family members should be provided. Opportunities for interactive patient education and wireless connectivity are encouraged. Family and children’s areas are included, as well as MyHealtheVet workstations.

Corridors and Connections:

minimum width) corridors accommodate wheelchair and/or equipment movement. The separation of patient and staff corridors enhances privacy and creates a quiet environment in clinical care areas. Security-sensitive planning and design concepts are incorporated into each clinic, such as controlled access points and visualization of patient transition areas.

Separation of Flow:

Patient spaces and circulation are visually and physically separated from staff and backstage circulation and space.

This reduces congestion, noise, and stress for both veterans and staff which is critical for veterans experiencing post traumatic stress disorder (PTSD). Privacy, security, and acoustics are improved while minimizing interruption of care and exposure to “off-stage” activities.

Clear Point of Entry Patient Greeting and Assistance Corridors and Connections

3.2 PACT Process

Figure 3.2-3

3.0 THE PATIENT EXPERIENCE

3.2 PACT Process

Visual Control Standard WorkBring Services to the Veteran

Visual Control:

Visual control enhances the patient’s care experience through simplified wayfinding. The design of the open teamwork zone enables visual control for staff; at a glance, the team can determine the availability of staff, supplies, and equipment. This approach speeds care to the patient, optimizing and supporting teamwork.

Bring Services to the Veteran:

Patient travel is minimized by bringing services to the patient care room. The Veteran is initially roomed and the staff will come to that room to deliver care whenever practical.

Blood draws, EKGs, after-visit summaries, pharmacy and other consults, and referrals may be discussed in the room.

Individual printers in each patient care room will enhance efficiency, saving staff and patient time.

Standard Work:

Standardization of workflow is facilitated through the use of standard room layouts and application of the PACT Space Module. Standard work improves quality, safety, and efficiency, minimizing the number of patient hand-offs.

Universal Care Room:

Standardized rooms based on modular/same-handed design readily adapt for use by different specialty services and evolving information/technologies. Identical layout and outfitting improves efficiency and reduces errors.

A change from primary care exam to specialty exam such as podiatry/orthopedics is facilitated by bringing in the appropriate mobile supply carts. The patient care room can be easily re-tasked between primary care, mental health consulting, optometry, or other uses by changing out furniture and equipment.

LVN/LVP SEES

PATIENT

PATIENT

CHECK-OUT

PROVIDER SEES

PATIENT

PATIENT

FOLLOW-UP

PATIENT CARE DEPARTURE

Figure 3.2-4

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

3.0 THE PATIENT EXPERIENCE

Patient-Centric Care Room Functional Requirements:

The Veteran is supported by the delineation of consultation and examination areas within the care room. The design of the room emphasizes the ability to share information between staff, the Veteran, and family.

Equipment and Supplies:

Commonly used supplies consistent with the primary use of the room are kept in a mobile cart in the patient care room. These are easily supplemented or changed out using additional carts with care specific supplies. Additional equipment is located in the teamwork zone, stored near their point of use and shared between multiple rooms.

Patient Relocation:

Rooming the Veteran is a primary operational objective in patient-centered care. When additional services cannot be delivered in the initial patient care room or the veteran would be more comfortably served in another location, the Veteran will need to travel to another location/room. These services should be conveniently located within the clinic.

Services may include extended consultation or education services, specialty procedures, diagnostic imaging, and the acquisition of lab specimens.

Non-Provider Services:

When Veterans are only visiting to receive diagnostic imaging, lab, or pharmacy services, the design provides the flexibility for Veterans to access those services directly.

3.2 PACT Process

LVN/LVP SEES

PATIENT

PATIENT

CHECK-OUT

PROVIDER SEES

PATIENT

PATIENT

FOLLOW-UP

PATIENT CARE DEPARTURE

Figure 3.2-5 Patient-Centric Care Room Diagnostic ServicesEquipment and Supplies at Point-of-Use

CONSULT

EXAM

3.0 THE PATIENT EXPERIENCE3.0 THE PATIENT EXPERIENCE

3.2 PACT Process

Follow-Up Planning Provider Summary and Instructions In-room Printing

Appointment, Follow-Up Planning, and Check-Out:

In the PACT Model, these activities ideally take place in the patient care room. Alternatively, a checkout kiosk/station may be located on the way out of the clinical care area.

Practice may vary from location to location.

Graphic and written materials for veterans can be printed during or after each appointment. This assists in providing the most recent and accurate information to veterans and their families. Materials may include test results, health education, provider instructions, and after-visit summaries.

Providing printers in patient care rooms enhances patient centered care as Veterans feel that the information was printed just for them. Veterans are encouraged to become more involved with their care, ask questions, and follow the provider’s directives. In addition, this also reduces the need to source and store handouts and forms.

LVN/LVP SEES

PATIENT

PATIENT

CHECK-OUT

PROVIDER SEES

PATIENT

PATIENT

FOLLOW-UP

PATIENT CARE DEPARTURE

Figure 3.2-6

4.0 PLANNING AND DESIGN

PACT SPACE MODULE P A T I E N T A L I G N E D C A R E T E A M

4.0 PLANNING AND DESIGN

4.1 Clinic Organization

The translation of the PACT care delivery model into a complementary planning and design concept resulted in the PACT Clinical Space Module (“PACT Space Module”) (Figure 4.1-1). The PACT Space Module is a single planning unit that contains the functional elements that support the operational flows needed to utilize PACT. The functional elements support the seven major operational goals introduced in Section 3 of this guide:

Bring Care to the Patient Support Flexibility and Adaptability

Provide Privacy and Security Streamline Processes Enhance Teamwork Simplify Wayfinding

Promote Healing and Well-being

While this PACT Space Module Design Guide is focused on the PACT Space Module, it is important to understand the relationship of the PACT Space Module within the context of an entire outpatient clinic. Therefore, this section also includes a brief introduction to the Integrated Clinic

- a planning approach that fluidly connects clinical areas across a given building - setting up the context in which the PACT Space Module will be utilized.

Figure 4.1-1 PACT Space Module Design Diagram

18’-0”

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U.S. Department of Veterans Affairs Office of Construction and Facilities Management

4.0 PLANNING AND DESIGN

4.1 Clinic Organization

31’-0”

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Figure 4.1-2 PACT Prototype Design Diagram

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In parallel to the development of the PACT Space Module, VA-CFM was conducting a CBOC Prototype Study through a VA Innovation Project. This Study arrived at a variation of the PACT Space Module;

the Team Work Zone is approximately 30 feet wide in the Prototype developed in the Study.

This width provides a greater net square foot area in the Team Work Zone. With this wider spacing, the Team Work Zone in the future could be reconfigured to include two 6’-0” wide corridors and enclosed functional space.

Utilization of the CBOC Prototype requires additional PACT Care Team members to be located in this Zone. To maintain the program level of net square foot area in the Team Work Zone, the length of the zone is shorter as compared to the PACT Space Module’s Team Work Zone. This results in approximately six (6) patient care rooms being located along the Patient Corridor with single door access vs. the dual door access as provided in patient care rooms that are located adjacent to the Team Work Zone. Staff in turn will utilize the Access Hallway and co-mingle with patients in the Patient Corridor to access these outer rooms.

If this outer layer of patient care rooms is positioned adjacent to the Team Work Zone, the length of the Team Work Zone would become greater, providing an excess of net square foot area in the Work Zone.

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4.0 PLANNING AND DESIGN

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4.1 Clinic Organization

Past clinic configurations that segregate clinical services have limitations with regard to supporting smooth clinical flows of veterans and staff across clinics and by this segregation, have evolved into isolated clinics. Solutions developed on a department-by-department basis have often led to disjointed flows and created inefficiencies and impediments to the patient experience (Figure 4.1-3). Additionally, a single, shared corridor for staff, veterans, equipment, supply, and circulation has resulted in congestion leading to interruptions, breaches in privacy, and increased security risks. Issues associated with legacy clinic configurations include but are not limited to:

• Increased travel distance and time for veterans

• Mismatches in demand and capacity

• Duplication of space, inventory, processes, and staffing

• Impeded communication, delays in care, dropped hand-offs

• Lack of collegiality and teamwork

• Amplification of error rates

The PACT Space Module creates circulation and flows that create Integrated Clinics (Figure 4.1-4). The layout streamlines patient flow and allows public functions and certain staff functions to span across multiple modules (Figure 4.1-5). The module establishes intuitive connections

Figure 4.1-4 Integrated PACT Clinic Patient Flow that simplify Veteran, staff, and public circulation both within and across clinical areas. The space configuration creates separate Patient Care Zones (on-stage) and Teamwork Zones (off-stage) which improves workflow and privacy.

Using on-stage and off-stage strategies and thoughtfully developed operational adjacencies, the integrated clinic design configurations are flexible and adaptable and can readily respond to care system evolution, allowing clinical services to change over time without major disruption to the patient experience.These strategies and adjacencies support processes that bring care to the veteran. Benefits of the Integrated Clinic include:

• Shorter travel distance and time for staff and Veterans

• Consultation and issue resolution in real time

• Alignment of demand and capacity

• Communication and transitions among staff

• Warm hand-offs between staff and Veterans

• Reduced wasteful and redundant activities

• Enhanced adaptability and flexibility

• Improved privacy

Figure 4.1-3 Legacy Clinic Patient Flow

U.S. Department of Veterans Affairs Office of Construction and Facilities Management

4.0 PLANNING…