Appendix 2: Form and function of the family medicine practice site

The following is an example of how to calculate the number of exam rooms a practice needs:

1. Estimate the number of visits per year by family medicine clinicians, including residents, faculty, and APPs (i.e., nurse practitioners [NPs] and physician assistants [PAs]). One option is to assess the clinic schedule per half day and plug in all of the clinicians’ clinic schedules to get a sense of the maximum number of clinicians who will be seeing patients each half day. (Note: A common error is underestimating clinic visits by not accounting for faculty and APPs, and thus not planning enough space for exam rooms.)
   1. This requires deciding on the practice model (e.g., mostly resident visits, significant faculty practice without residents, use of APPs).
   2. The FMP site should have at least one available exam room per 1,000 patients seen per year.
   3. Family medicine clinicians should have at least two exam rooms when in clinic.
   4. Faculty and third-year residents (and fourth-year residents and fellows, if applicable) could each be assigned three rooms when in clinic.
2. Add other health care professionals who see patients at the FMP site (e.g., mental health professionals, substance use disorder treatment professionals, subspecialists).
3. Add one to two procedure rooms for a clinic that has at least 25,000 patient visits per year.

The estimate that one exam room is needed per 1,000 patient visits per year at the FMP site assumes that all clinicians have at least two exam rooms when in clinic. Often, a faculty physician or senior resident may get three exam rooms, particularly when they are working with students. It is possible to have a tighter schedule in which PGY-1s get one exam room and other clinicians never get more than two exam rooms, but this becomes impractical when the number of clinicians assigned to clinic on a given day is variable, as is often the case in residency clinics.

Having medical students and other learners at the FMP site increases the need for exam rooms, particularly for senior students. To maintain a full schedule and stay on time, a senior student needs space in which they can spend time with each patient doing their own interviews, exams, assessments, and patient education while their supervising faculty or resident is seeing other patients on their own schedule.

Rooming tasks for nurses have expanded as more comprehensive care is expected at every visit. If the number of exam rooms in the FMP is limited, nursing time can become a barrier to efficient physician time with patients. Some clinics operate on a “self-rooming” model, which can greatly decrease the need for waiting room space but requires enough open exam rooms for self-rooming to be practical.

In light of all these considerations, a Program of Excellence should not increase the “one exam room per 1,000 patient visits per year” estimate to one exam room per 1,200 to 1,300 annual patient visits. This will put stress on the FMP site and is not an excellent plan for patient care, clinic flow, or resident and student education.

In addition to having an adequate number of exam rooms, a Program of Excellence will have precepting space that provides enough room for the number of faculty physicians needed on a busy resident day. The space should be arranged so that each faculty physician can have a reasonably private—or at least not easily heard—conversation with one or two residents or a resident and a student without excessive wait times for residents who need real-time guidance about patient care.

The FMP site should have space for group visits, as well as areas in which residents and faculty can conduct telemedicine visits with separation that meets Health Insurance Portability and Accountability Act (HIPAA) privacy standards. There should also be adequate conference room space in or near the clinic. The practice space’s design should facilitate close communication between clinicians and nurses. To facilitate warm handoffs and ongoing communication, comprehensive support services (e.g., behavioral health professional, pharmacist, nurse educator) should be readily accessible to clinicians within the practice. Waiting room space should be attractive and allow patient distancing, and it should be scaled to the practice’s clinic flow model (e.g., self-rooming, traditional nurse rooming).

A Program of Excellence that is considering innovative design and construction should incorporate elements to address changes in health care delivery systems. In some cases, movement to an evolved team-based care model can be impeded by the physical layout of the clinic. An innovative approach may also be important to attract and retain patients, residents, and staff.

• Design and construction that support care delivery system changes may include some or all of the following elements:
• Involve all staff in building planning and remodeling to increase their sense of ownership and commitment to the clinic. The Quadruple Aim includes clinician and staff satisfaction. Satisfied clinicians and staff are known to deliver better care and increase patient satisfaction.
• Design a waiting room that meets the needs of the practice’s care model and size. Ideally, it should have separate sick and well patient sections. Depending on the practice, the waiting room may include beverage service, a health bar, patient education information, celebrations of local diversity, or kiosks for electronic check-in and checkout. A self-rooming model can decrease the amount of waiting room space needed if the number of exam rooms is generous.
• Provide central team space that allows clinicians and other members of the care team to sit near each other while managing visits and allows for non-visit panel management.
• Include fewer private offices and more team space.
• Provide a room that allows nurse care coordinators to conduct panel management and also interact with visit-based daily workflow.
• Include a room that can be used as a residency meeting room and can also be used for other department functions, for clinic functions and meetings, and/or for meetings with community groups, as needed.
• Incorporate flexibility into the design to give the option of a smaller operation in a reduced number of exam rooms on evenings and weekends. This requires fewer nurses and less front desk staff and maintains building security by locking off much of the rest of the building.
• Depending on the practice’s staffing and care model, designate space for provision of dental care and mental health services, as well as space for pharmacists to educate patients and interact with clinicians and nurses.
• Consider creative ideas such as having a community garden and/or a farmer’s market in the parking lot on weekends.
• Consider clinic design that promotes staff wellness (e.g., space for yoga classes) and provide a nice outside dining area.