Premises
Practice Management Committee of Council
Location
The geographic location of the surgery building may be decided by factors other than personal choice. A commercial building may have rooms available for lease, a shopping centre may contain purpose build rooms, or adjacent land available for development, or an existing private home may be suitable for remodelling.
Whatever location is chosen, the decision to rent or lease, buy or build, must eventually be made. Consultation with an accountant and architect is essential as knowledge of local council zoning regulations, legal requirements, industrial legislation and requirements of statutory bodies will influence the final decision. A visit to the local authority planning division has been mentioned. It is worth repeating.
The surgery should be close to public transport and accessible. This may require noise screening with trees planted close together, a noise deflecting wall, or landscaping with an earth bank. One needs to balance consideration of noise abatement against the desire to locate the surgery in an open environment, easily visible to potential patients.
Regulations may require on-site parking (the local council will advise you of the required number per doctor) with provision for a larger bay near the entrance for ambulance and handicapped persons. A ramp should be provided and if steps are used, a handrail is necessary. The entrance should be protected from the weather. The building should be floodlit for burglary protection.
An attractive and easily read sign should advertise the surgery and provide other information about consultation times and after hours telephone numbers. The size and style of signs will need to comply with the local council and State Medical Board regulations.
Reception
The reception area is the hub of the business section of the surgery and the initial impression it makes on patients will be lasting. The area should be business-like and professional providing privacy, dignity and convenience for the patient. It should have easy access to other rooms and a view of the waiting area. It should be large enough to accommodate the full staff during normal working hours and convenient enough to be manageable by one person at other times. The counter should be uncluttered but provide for appointment books, billing and receipt documents and telephone. A district map showing the location of other health care facilities will assist staff in directing patients.
Other items of business equipment (typewriter, calculator, FAX, photocopier, computer) will be housed in this area and medical records will be within easy reach. Built-in furniture should be used sparingly to provide for expansion and elaboration.
The size of the room will depend on the number of staff. A rough guide is a minimum of 10 square metres with 5 square metres additional for each employee. Medical record storage will require enough wall space with open steel shelving to provide about 250mm per 100 records.
It is important to reduce to a minimum the distance that your staff have to move in their work. The telephone, appointments register and record index (if there is one) should be within arm's reach and at a level that obviates bending. By the same token, at least part of the counter should provide a writing surface at standing height for patients signing forms or writing cheques. Conversations at desk or telephone should be inaudible in the waiting room.
Waiting room
The size and style of this area will depend on the type of practice. A solo practitioner who sees three to four patients an hour on an appointment basis will require entirely different waiting room facilities from a large busy clinic. However, some features will be similar. Attention must be paid to the ambience of the room, with good quality furniture and a suitable colour scheme for a pleasant, friendly, relaxed atmosphere. Indoor plants and a fish tank are now a traditional feature of waiting rooms. Noiseless toys should be provided.
Music is useful to avoid tense silences and as an aid to privacy by blocking other sounds. Paintings may be leased from a gallery or provided by a local art group. Up to date magazines, a rack for health literature pamphlets, and a notice board for surgery information, community and preventive health care notices should be provided. Provision for audio-visual aids may be wise. A vestibule for umbrellas, coats and prams is useful. If space permits, a separate children's play area with play equipment, even a corner away from the main passageway, could be provided. Seating should be chairs with arm-rests, not benches and arranged in groups. The number of seats provided should be three times the peak number of patients per hour, allowing 1 square metre per chair minimum room area. The number of seats is variable, but the space critical. Some patients are accompanied, perhaps by the whole family, but many people are alone and you must be guided by your own experience.
Consulting room
The consulting room must be a pleasant, efficient place to work with furnishings that express the individuality of the doctor.
Flexibility is important to cope with around the desk consultations, family counselling, acupuncture or hypnotherapy. A combined consulting or examination room is usual and if more than one is used, the layout should be identical and adjoining. A rectangular room of about 12 square metres with the doorway at one end or the long wall is the most suitable design. The examination area should be separated by a partition or curtain, and natural lighting is ideal.
Distracting material for young and older children will prevent havoc with your valuable instruments. Dangerous objects (glass ampoules or needles) should be consigned to a 'sharps' container kept out of each of toddlers. Some jelly beans are useful.
Ancillary rooms
There may be considered under three headings:
Clinical
A multipurpose area for the care of emergencies and minor surgery, procedures such as plastering or diathermy and investigations such as ECGs and spirometry. The size is a function of the ambitions and necessities of the practice but it must be large enough to accommodate and manoeuvre a wheel chair or stretcher and long enough to test distant vision with an eye chart. If possible it should have a direct access to the outside world, separate from the normal entrance and must be out of sight and sound of the reception/waiting room. The clinical room should be equipped with chairs, desktop, diagnostic instruments and stationary. It will double as a spare consulting room if required. Containers for disposal of sharps or other dangerous waste are needed.
Preparation space. Here are sterilisers and/or autoclave, and a means of escape for the steam they generate, dressings, instruments, splints and bandages. Designers would do well to consult the practice nurse, whose domain this is, about cupboards, working surfaces and general layout. This too is probably the place for the refrigerator for vaccines, test sera, drugs and specimens.
Investigation area. It may only be a table with a microscope, some Clinistix and a bucket, but it demands separate consideration and should, if possible be adjacent to a lavatory with intervening hatch for delivery of samples without delay or embarrassment.
X-ray and dark room may be an option. This must be so situated as to cause no hazard to patients or staff. Standards for construction materials, directions and limits of radiation are set by the State health authorities. Protective clothing and screening must be provided. There should be room to manoeuvre stretchers and wheel chairs. The dark room needs running water and drainage. It must be light tight with a separate 'dry area' for storage and handling cassettes and film away from damp and injurious chemicals. Special care is required to ensure that any women who may possibly be pregnant are not exposed to radiation or other hazards.
Office
The general office area should be adjacent to or part of the reception area and designed to economise movement and effort for the users. Open shelving is easier and more flexible than filing cabinets although there must be secure and fire proof storage for cash and essential documents. The space should be 12 square metres for the first staff member and 7 square metres for each additional person.
Staff room and library. The staff should have a comfortable and suitably equipped room with their own toilet and basin and means of making hot drinks and washing up.
If space permits a room equipped with stationary and telephone and furnished with shelves for books, journals and other reference material provides a retreat and a meeting place where colleagues, medical and paramedical, can drop in for refreshment, informal discussion or research.
Storage and toilets
Local councils lay own the numbers and construction details required. It is wise to delegate someone to check toilets at least twice daily and to provide door catches which can be forced if the need arises.
The size of storage areas should be estimated with the principle that no good nurse ever discards an instrument, no good secretary a record, or no good doctor an x-ray or drug sample. The initial estimate should be doubled and 50% added for the cleaner's tools and materials.
General considerations
Whether building or adapting, you should give some thought to the traffic flow through the rooms. Taking the Reception/Waiting area as the hub, try to plan the spokes of consulting, treating and investigating in such a way that you and your staff can move freely and as little as necessary, if possible out of sight of waiting patients. A separate entrance for emergencies, suitably sized and positioned for ambulance access, is very helpful, and a separate entrance for yourself and staff desirable.
Natural lighting of sufficient brightness may not always be possible and diffused light either from ceiling baulks or reflected from walls is preferred.
Sound and noise control requires good architectural design and choice of materials. Several problems require consideration:
- External noise from traffic, aircraft, industrial sources or air conditioners, should be minimised to make working conditions pleasant.
- Internal noise from typewriters, computer printers, telephones and conversation buzz is acceptable if at a low level.
- Distinctive surgery noises must be screened, such as noise from a plaster saw, or clinking of instruments.
- Special provision should be made for fractious children.
- Care should be taken to ensure that dialogues with patients are not overheard by other people.
- Where possible noise should be blocked by adequate sound proofing or masked by unobtrusive music.
Smells of disinfectants, anaesthetic agents, cigarettes and unpleasant human odours must be removed from individual rooms, and not recirculated through the air conditioning or through open windows.
It is now common either to ban smoking or confine it to a specified area, such as a verandah and surgery staff should respect these rules.
Heating and cooling requirements will depend on the climate and overall building design. In general, a building with a long axis running east-west and most windows opening north-south will be easier to manage.
Security
Consider the following issues:
- Day and night usage. Building should be designed for maximum usage when all staff are present and patient numbers are maximal during day hours. But the building and its facilities should be designed for partial closure at night when perhaps only one doctor and one receptionist are present. Staff should be always vigilant for prowlers, and strangers should not be left alone in the consulting room.
- External flood lighting at night and security lights.
- Internal security of money, drugs, prescription pads, ledger files, medical records, both from burglary and fire. It is recommended that stock of prescription pads be numbers and issues to doctors from store as required.
Crime prevention bureau and private security services offer free advice. Insurance cannot replace intangibles like convenience and confidence for staff and patients.
Other suggestions for patient comfort and convenience:
- Wide passageways.
- Door that open widely in the correct direction.
- Room signs.
- 'In use' signs on doors.
- Red telephone.
- Tea and coffee making facilities.
- Private areas for feeding and changing babies.
Adapted from Running A Successful General Practice