Influence of Environmental Design on Team Interactions Across 3 Family Medicine Clinics: Perceptions of Communication, Efficiency, and Privacy

Abstract

Purpose

To explore how two different primary care clinic physical layouts (on-stage/off-stage and pod-based designs) influenced pre- and post-visit team experiences and perceptions.

Background

Protocols encourage healthcare team communication before and after primary care visits to support better patient care and population health. Physical clinic environments may influence these behaviors, but limited research has been performed.

Methods

We conducted observations, three interviews with clinic managers, and six focus groups with 21 providers and staff at three family medicine teaching clinics. Observational data was captured through field notes and spaghetti diagrams. Interviews and focus groups were recorded, transcribed, and analyzed using a grounded theory-based approach to understand how aspects of the clinic environment affected communication, efficiency, and privacy.

Results

Variations in communication styles and trade-offs between patient contact and privacy emerged as differences. In the on-stage/off-stage design, colocated teams had increased verbal communication, but perceived being isolated from other clinic teams. In contrast, teams in pod-based clinics communicated with other clinic teams, but had more informal patient contact within care-team stations which imposed privacy risk.

Conclusions

Primary care clinic design appears to alter provider-team and patient-provider communication and flow. If findings are replicated, organizations should consider aligning environmental design with desired interaction patterns when building new primary care clinics.

Executive Summary of Key Concepts

The physical spaces that we work in affect the work we do; however, little research has been done in primary healthcare exploring how physical clinic environments may influence team communication. This study explores three family medicine clinics and compares two respective designs, (1) an on-stage/off-stage design, sequestering staff in enclosed areas, and (2) a pod-based clinic, embedding providers within open nurses’ stations. Through observations in clinic areas, interviews with each clinic manager, and focus groups with 21 providers and staff, themes emerged around communication, efficiency, and privacy. A trade-off between patient contact and privacy emerged in addition to variations in communication styles. In the on-stage/off-stage design, colocated teams’ communication thrived, but they perceived being isolated from other teams in the clinic. In comparison, teams in pod-based clinics had no such issues communicating with other clinic teams, but had more unexpected patient contact outside of the visit in care-team stations and the ensuing privacy risk.

Design of the physical environment is likely a critical and relatively unexplored factor influencing worker behavior in primary care settings. This topic is particularly important given the growing emphasis on team-based care and the adoption of care models that encourage collaboration to enhance care delivery (Gulwadi, Joseph, & Keller, 2009; Jackson et al., 2013; Kapinos, Fitzgerald, Greer, & Rutks, 2012; McGough, Jaffy, Norris, Sheffield, & Shumway, 2013; Wagner, Austin, & Von Korff, 1996). In team-based care models, the time surrounding patient visits is utilized for planning of pre-visit work (e.g., needed laboratory tests) and post-visit work (e.g., coordination of patient follow-up). These pre- and post-visit practices can be promoted or constrained by a clinic’s design.

In and outside of health care settings, environmental design factors have been shown to support group interaction and collaboration by colocating teams so members are kept in close proximity or by dispersing work areas to promote informal meetings (Augustin & Brand, 2009; Gunn et al., 2015; Heerwagen, Kampschroer, Powell, & Loftness, 2004; Hess, Reed, Turco, Parboosingh, & Bernstein, 2015; Keller, Joseph, Taylor, Quan, & Unruh, 2011; Springer, 2007; Ulrich et al., 2008). In outpatient settings, well-designed team stations have also been described as improving efficiency, strengthening culture, and supporting communication (American Medical Association, 2015; KI, 2015). However, the influence of different outpatient clinic designs on health care staff perceptions of team functioning is not known.

Traditional outpatient clinic layouts limit natural collaboration between staff and providers that can occur through interacting as part of customary patient and staff flow patterns. In these designs, nurses and medical assistants work in care-team stations and providers work in private offices. In contrast, two decentralized clinic layouts take a different approach. The on-stage/off-stage (OS/OS) design keeps teams physically separated from patient areas. The pod-based (PB) design intersperses patients and health care workers in common areas (Keller, et al., 2011). The purpose of this study was to explore how these two decentralized layouts for primary care clinics influenced pre- and post-visit team experiences and perceptions of communication, efficiency, and privacy.

Methods

We conducted a qualitative study to draw comparisons between team interactions in an OS/OS or PB environment. The University of Wisconsin Health Sciences Institutional Review Board approved this study (IRB 2014-0516).

Setting

Three family medicine clinics were chosen purposively to compare clinic design types. One clinic was an OS/OS design and two were PB. All clinics had been constructed in the past 4–7 years, were 16,000–32,000 square feet, and were staffed similarly (6–8 physicians). Care-team stations and provider offices were dispersed around examination rooms. Most care-team stations housed a single team; however, in PB designs, a single larger care-team station was sometimes home to multiple teams depending on team schedules.

On-stage/off-stage design.

The OS/OS approach is organized between private staff and public patient spaces and keeps the behind-the-scenes work of patient management invisible to patients. In this clinic, patient rooms have dual access, allowing patients to enter from a front corridor and staff to enter separately from a back work area. These work areas, completely closed to the public, are places where providers and clinical staff are colocated. A work area is shown in Figure 1.

Figure 1.

Photograph of onstage/offstage (OS/OS) closed work area showing perspective from within the OS/OS care-team station showing a shared work area. On the left side of the image is a door to an examination room. The patient entry/exit is not visible from this area and is on the other side of the examination room. Dotted area indicates busy areas where the most interactions occurred during the observations.

Providers have offices on a second floor accessible off-stage without having to enter on-stage areas. Additionally, staff do not have to walk all patients to examination rooms. Instead, medical receptionists provide instructions and/or a map to patients, who then walk unaccompanied to the room (Kamnetz, Marquez, Aeschlimann, & Pandhi, 2015). In this model, clinical staff move between on-stage and off-stage areas, whereas providers are often deeply off-stage, as shown in Figure 2.

Figure 2.

Onstage/offstage clinic (left) and pod-based clinic (right) design showing work area in relation to patient areas and care-team station in detail. Dotted area indicates busy areas where the most interactions occurred during the observations.

Pod-based design.

PB clinics included open care-team stations. Patients, staff, and providers all enter patient rooms through the same corridor and door, as shown in Figure 1. Providers are not necessarily colocated in staff work areas (care-team stations), but can use available touchdown stations (workstation available on first-come, first-served basis) in the care-team station. A care team station is shown in Figure 3.

Figure 3.

Photograph of pod-based open work area showing perspective from within the PB care-team station showing an open shared work area. Behind the viewer and in the back of the photograph, examination room doors are shown in hallways shared by patients and teams.

Data Collection

Direct observations, interviews with the 3 clinic managers, and 6 focus groups with providers and staff were conducted at the three clinics by a researcher trained in qualitative methods and human factors engineering. Providers were physicians and physician assistants. Staff were medical assistants, registered nurses, and medical receptionists.

Observations and interviews.

Forty hours of participant observations were conducted per clinic. Observation areas were selected based on the flow that occurred during a patient visit. Medical receptionists were observed as they performed their primary duties around registration/check-in and check-out. Clinical staff (medical assistants and nurses) were observed performing their duties occurring primarily at care-team stations and at check-in. Primary care providers (physicians and physician assistants) were primarily observed in care-team stations and offices. Observational data were recorded in a physical notebook and transferred to electronic notes. Spaghetti diagrams (diagrams indicating walking path frequency) and activity notes were obtained. Diagrams traced staff and provider walking paths to identify areas of high-traffic that could serve as cues for focus-group discussion.

Interviews lasting ~45 minutes were conducted with each of the three clinic managers to confirm observational findings. Observations were conveyed through a structured interview and review of walking paths, drawn on the blueprint of the clinic.

Focus groups.

Key focus group discussion topics and probing questions were developed from analysis of the observational and interview data. Topics were centered around physical areas of interest throughout the clinic (e.g., reception). One provider and one clinical staff focus group was conducted at each of the three clinics. Each focus group included at least one member from each role (physician, physician assistant, registered nurse, medical assistant, medical receptionist). Focus groups lasted 90-minutes and included 3–4 participants. Participants were shown a series of projected photographs of clinic physical spaces along their routine walking path. For example, providers were shown photos depicting the walk from workspace to exam room. For each photograph, participants were asked: what was done here, what features obstructed them from doing those tasks, what features might help them complete those tasks, and about any other impressions.

Analysis

Focus group data were recorded, transcribed, and reviewed for accuracy. Using principles of constructivist grounded theory (Charmaz, 2006) transcripts, interviews, and field notes were coded. Constant comparison, whereby analysis occurred simultaneously with data collection, was used. Data were coded in an iterative process by the lead author through periodically presenting the ongoing analysis for critical discussion and feedback from two multidisciplinary groups, in addition to the managers at each clinic. The first group consisted of a qualitative research group of principal investigators and the second was a writing collaborative that included practicing primary care physician leaders. This feedback informed interpretation and was used to determine focus group topics and revise analysis following initial coding. Next, the data within and across codes were examined to identify key themes relevant to participants’ perceptions of the clinic design. Lastly, illustrative quotes were selected to highlight central themes.

Results

Participant demographics are displayed in Table 1.

Table 1.

Focus group participant demographics (n=21)

		N (%)
Role
	Physician	5 (24)
	Physician Assistant	4 (19)
	Registered Nurse	3 (14)
	Medical Assistant	4 (19)
	Medical Receptionist	5 (24)
Gender
	Female	19 (90)
Age
	18–24	1 (5)
	25–34	10 (48)
	35–44	3 (14)
	45–54	4 (19)
	55–64	3 (14)
Race/ Ethnicity
	White	21 (100)
Years worked in health care
	Mean	13
	Median	9
Highest education level completed
	Associates or Some College	7 (33)
	Bachelors	6 (29)
	Masters	2 (10)
	Doctoral	6 (29)
Marital status
	Married	15 (71)

Major Observations Validated Through Manager Interviews

Distinct provider communication and work patterns were observed in both clinic types. Figure 1 depicts areas of frequent interactions. In OS/OS clinics, providers tended to work and communicate in care-team stations despite having private offices. Frequent informal interactions occurred between providers and staff in these care-team stations. Providers in PB clinics also engaged in infrequent formal check-ins in care-team stations with most communication between visits occurring in entryways to care-team stations; however, PB clinic providers tended to work more in their offices rather than in care-team stations as they lacked dedicated workstations. While open touchdown workstations were available, they were rarely observed in use. In both clinic types, huddles were conducted once daily in the OS/OS clinic’s care-team stations and in the PB clinics’ offices to discuss pre-visit activities, updates on patients with chronic conditions, and upcoming procedures. As these all were teaching clinics, learners (medical students, physician assistant students) were present. In PB clinics, learners used the open touchdown stations. In the OS/OS clinic, learners used any available workspace in the care-team stations.

Focus Groups

Twenty-one focus group participants described 6 themes related to communication and efficiency and 5 themes related to privacy and workspace design. These themes are contrasted between the two clinic designs.

Themes: communication and efficiency.

Balancing communication within a care team and across clinic teams.

OS/OS providers were dissatisfied with communication across clinic teams and perceived being isolated from other teams in the clinic. Providers and staff were concerned that they were unaware of what was happening in other clinic areas during the workday. Teamwork between clinic teams was perceived as limited and one provider missed the feeling of “one big team.” Distance between teams was a factor limiting regular consultation with other providers in the clinic, outside of those located within an off-stage care-team station. However, in PB clinics, teams experienced communication challenges arising from shared spaces, such as task interruptions due to noise from different care teams. In OS/OS clinics, noise was able to be effectively mitigated due to the nature of the work area being behind closed doors.

Facilitating meetings between providers and clinical staff.

In the PB clinics, providers often formally checked in daily with clinical staff (either by phone or in person using a structured plan at a planned time), whereas informal check-ins (spontaneous and without a structured plan) were more common in the OS/OS clinic. In the PB clinics, formal check-ins between clinical staff and providers occurred in provider offices, including one-on-one pre-visit planning meetings, physician assistant consults with physicians, and huddles. In the OS/OS clinic, a group meeting area (called the “armpit”) designed into the care-team station provided a place to huddle and review complex patients or the day’s work. Team huddles were often used for pre-visit communication in the OS/OS clinic. In PB clinics, providers preferred to work primarily from their offices (described as a quiet and private work area for documentation), rather than care-team stations, to limit perceived inefficiencies from face-to-face interactions. Providers perceived wasted time resulting from needing to walk between their offices and examination rooms as hindering their ability to complete administrative work.

Promoting incidental face-to-face communications.

Care-team stations facilitated communication in different ways. All clinical staff found value in “quick” feedback during face-to-face interactions with other team members in care-team stations. They perceived that these communications resulted in time savings through not having to send messages via the electronic health record (EHR). Providers in the OS/OS clinic worked in care-team stations between visits more often than PB clinic providers and experienced more of this face-to-face communication. OS/OS providers were very satisfied with the benefits of these communications, describing them as “efficient” and resulting in a “significant time savings aggregate,” but described inefficiencies in their personal workflows. However, in the PB clinics, providers were rarely in care-team stations and primarily visited to retrieve printed material (e.g., prescriptions). Unlike OS/OS providers, PB providers primarily communicated face-to-face in their offices.

Other time-saving benefits of face-to-face communication included the need for fewer telephone calls, and the ability to address emergency issues as they occurred. Providers appreciated receiving laboratory results before meeting with clinical staff. Areas of dissatisfaction for providers during face-to-face communications in care-team stations included redundancies (e.g., staff repeating information previously documented in the EHR).

Preferring colocation.

Differences emerged in providers’ descriptions of their working areas and whom it included. PB providers, who worked more commonly outside of their provider offices, referred to the working area as including examination rooms, physician offices, and other care-team stations in the clinic; whereas, providers working in the OS/OS model included only their immediate care-team members in the enclosed care-team station. OS/OS providers were more easily able to access the immediate team in the care-team station. In contrast, providers in the PB clinics were often dissatisfied with their inability to locate their clinical staff, especially if they were seated far away. This was contributed but not solely due to staff spending time rooming patients in the PB clinics. The communication challenges created by not locating clinical staff were perceived by providers as limiting productive documentation time.

Connecting with patients outside of the office visit.

In the OS/OS design, providers generally were dissatisfied about the physical separation from patients because they were located in off-stage areas inaccessible and unseen by patients. One OS/OS provider said of the off-stage area, “It feels like all this is separate from me and my practice.” Providers were also concerned about not being able to see patients leaving the exam room.

Both providers and staff in PB clinics experienced interruptions from lost patients requiring assistance and patients who wanted to talk with a provider. PB providers and staff spent time redirecting patients whereas the OS/OS clinic did not experience these interruptions (as off-stage work areas were not directly accessible to patients). Not all providers and staff saw this patient contact as intrusive and some staff enjoyed these interactions.

Connecting with patients after the office visit.

In the PB clinics, providers and staff assisted with patient wayfinding by walking patients out: primarily patients who were new, elderly, or required more complex post-visit planning. This required provider time to complete, but was perceived as necessary for new patients because “otherwise they get confused.” However, busy check-out areas discouraged providers from this practice. PB providers also gave verbal instructions to patients on how to get to check-out, using either physical waypoints (e.g., advising patients to turn right and then left) or referring to the informal signage used to indicate where check-out areas were. Patients in the OS/OS clinic were not observed being walked out and instead were able to walk out unassisted. Providers were satisfied with using the map that patients are given at check-in to direct patients to the check-out area.

Contrasting themes related to communication and efficiency between clinics are summarized in Table 2.

Table 2.

Contrasting themes related to communication and efficiency between clinic designs with supporting quotes

Theme	Overall Finding	Supporting Quote from OS/OS and PB Clinics
Balancing communication within care team and across clinic teams	Communication between teams (called “pods”) in the OS/OS clinic were limited by separate, enclosed spaces which enhanced communication within teams; whereas in PB clinics, communication occurred but noise from other teams distracted.	OS/OS: I feel like the pods are segregated. We don’t get to know people in the other two pods because you’re not interacting with them. While it’s a nice sense of teamwork in your pod, you lose that with the other pods. PB: I talk mostly within my care team, although I do interact with [staff on other teams in the clinic] because of the proximity to my office. I might ask an RN in that pod for help. But I do talk to the providers from all care teams.
Facilitating meetings between providers and clinical staff	OS/OS care-team stations provided areas in the care-team station for meetings; whereas in PB clinics that lacked this space, meetings occurred almost exclusively in physician offices despite staff preferences otherwise.	OS/OS: [The group workstation is] used during the diabetic huddles… right in the morning so there’s not a lot of commotion. PB: Nurses and providers will huddle in their office and discuss patients. It’s an effective place for discussion. The provider offices are far away from the exam rooms so it’s secure for discussion.
Promoting incidental face-to-face communications	Incidental communications with productivity trade-offs were more common in care team stations in the OS/OS clinic, but less common in PB clinics where face-to-face communication consistently and preferentially occurred in provider offices.	OS/OS: I feel like sometimes it’s hard to stay focused, like whenever I’m sitting in the [care-team station] because people are walking by, they’re stopping to talk to you, they’re asking you questions. So I wasn’t as productive and getting as much done. PB: [It’s helpful] for the quick little answers, if you want to do a lab before their clinic… instead of calling or walking to find them. Just little questions that could save an extra phone call or extra time.
Preferring colocation	Close proximity to team members makes interactions easy in the OS/OS model; whereas in the PB model, there were perceived challenges reaching support staff.	OS/OS: So when I have the patient on the phone, I can get immediate feedback if they’re sitting right there versus routing them the account or waiting however long for them to route back. If I have a patient in a room then I can go out and find a provider, so that’s nice. PB: Well I think [the current clinic design] is dysfunctional because I can’t communicate with my nurse easily, and it wastes time.
Connecting with patients outside of the office visit	In the OS/OS model, providers were dissatisfied with being physically separated from patients; in the PB clinics, staff enjoyed seeing patients but experienced interruptions from lost patients.	OS/OS: You’re very protected here from seeing patients and their families, so, I don’t know who’s here. They’re not walking through our space, so there’s that, like, back a forth, where you see patients and can maybe check in for a little bit. That’s no longer there. PB: I do like to see [patients]. I think I talk to our patients more than I actually physically see them. It’s nice when they’re coming out of an exam room and they introduce themselves. ‘Hey, I talked to you on the phone [with] breathing difficulties. I’m really glad to see you’re doing better.’
Connecting with patients after the office visit	Elderly and new patients needed support getting to check-out in all clinics; but a map in the OS/OS clinic streamlined the process.	OS/OS: Patients feel really reassured when you hand them a map. PB: Navigating the building is so challenging. It is a really big challenge for patients.

P=provider quote; S=staff quote

Themes: privacy and environmental preferences

Challenging privacy outside of the office visit.

OS/OS providers often had concerns about what could and could not be heard by patients. While providers in the OS/OS clinic were dissatisfied by not seeing patients, providers and staff in the PB clinics had to respond to patient interruptions. PB clinical staff described patients entering care-team stations primarily for viewing x-rays, or following a provider who was entering to retrieve a prescription from the printer. Since PB care-team stations were open without doors, nurses were concerned about violating privacy standards, including patients hearing phone calls or viewing the EHR. While staff appreciated seeing patients in person with whom they had interacted with only via the EHR, in one case, it was considered necessary to address repeated privacy risks by designing signage instructing patients not to enter the care-team stations.

Pursuing direct views of team members.

PB providers often contacted staff by entering the care-team station, whereas staff had to often search providers out, rather than using the phone or EHR. PB providers were dissatisfied with time spent searching for staff. Providers in PB clinics were satisfied when they had a “direct view” of clinical staff or were able to look out of examination rooms and immediately convey clinical needs to staff. Dissatisfaction around searching for staff did not emerge in the OS/OS provider group; instead, providers commented on not needing to “chase someone down.”

Seeking customizable workspaces.

Providers in all clinics appreciated being able to customize private offices, but OS/OS providers and staff were also disappointed at the inability to personalize workstations in care-team stations, specifically in terms of quick reference materials, expanding storage, and addressing ergonomic issues. PB providers were more focused on optimizing their office space to better consult with staff and other providers, in addition to documentation. Providers in both PB clinics desired to face the door in their offices and indicated that an ideal layout would need to accommodate simultaneous consultation and computer screen viewing and mitigate privacy risks.

Choosing between shared and private workspaces.

Providers in the OS/OS clinics rarely spent time in offices and instead preferred to work in care-team stations for efficiencies resulting from colocation. However, PB providers preferred their personal offices for enhanced privacy and to reduce interruptions and were dissatisfied working in care-team stations. PB providers expressed a desire for easily accessible, private work areas to use between office visits that were not existent in the PB clinics.

Emphasizing patient privacy.

At all clinics, concerns about compromised patient privacy were common among reception staff. OS/OS staff experienced an unintended consequence where enclosed check-out spaces designed to promote privacy didn’t effectively mitigate noise in other areas of the clinic. Open spaces designed to promote accessibility for patients were perceived to compromise patient privacy at registration.

Contrasting themes related to privacy and environmental preferences between clinics are summarized in Table 3.

Table 3.

Contrasting themes related to privacy and environmental preferences between clinics with supporting quotes

Theme	Overall Finding	Supporting Quote from OS/OS and PB Clinics
Challenging privacy outside of the office visit	OS/OS teams were concerned about what could be heard, but PB teams were dissatisfied with privacy risks from patients inadvertently entering care-team areas.	OS/OS: I think that patients can hear what I’m saying at my desk, to be honest. Because when I’m in there rooming a patient I can sometimes hear people very clearly. And I don’t think everyone realizes that people can hear you. PB: … the biggest issue is the computer screens being open and patient information on. I could be talking to their neighbor. I don’t know who is standing behind me.
Pursuing direct views of team members	Line of sight was described as valuable, and providers were dissatisfied when it was not available.	OS/OS: It’s really efficient having a nurse in a pod when you need things like starting an IV, instead of having to run around and chase someone down. It’s nice having someone right across from me that I can talk to. PB: I think if you add up the amount of time I spend searching for somebody, it’s probably not, but when I do need [nursing staff], it’s frustrating if I have to take extra time to find somebody.
Seeking customizable workspaces	OS/OS providers were interested in care-team station changes related to quick references and textbooks; PB providers were interested in office changes related to ergonomics, privacy, and consultations.	OS/OS: I like to have charts and tables and things that I reference often and in the armpits. We just don’t have much bulletin board space because the wall is physically too small for it. PB: I didn’t put cabinets in [my office]. I have a bulletin board behind my computer. It’s nice to have a second one to tack up phone numbers. I wish I had more bulletin board space to put up little cheat sheets.
Choosing between shared and private workspaces	OS/OS providers rarely spent time in offices and preferred care-team stations between visits and described benefits of colocation; whereas PB providers preferred offices over care-team stations due to lack of privacy and were dissatisfied working in care-team stations.	OS/OS: I actually prefer this work space versus the office just because I like being next to the staff and having the ability to talk to them while they’re on the phone, or brief interactions between going in and out of rooms. PB: When I’m interacting with patients all day long, it’s really important for me to have my office with no one else in it… I feel like I’m more efficient … by myself. I love having my office and I never do anything in the nurses’ station.
Emphasizing patient privacy	Receptionists were concerned about patient privacy across designs at registration and check-out.	OS/OS: We have patients standing right next to each other and they can hear each other. They can listen in on what the other person checking in is saying. There have been some privacy issues. PB: Other patients can hear everything that we’re saying. There’s no privacy whatsoever. When we are doing mammogram orders, we ask “Have you ever had a mastectomy? Which side?”

P=provider quote; S=staff quote

Recommended goals for clinic design.

Teams’ needs and goals varied and conflicted in some cases. Preferred environmental attributes from the findings above are summarized between providers and staff across both clinic designs in Table 4.

Table 4.

Roles and corresponding preferred environmental attributes across both models

Role	Preferred Environmental Attribute
Providers	Opportunities to connect with other care teams in the clinic
	Quiet locations near examination rooms for visit documentation
	Line of sight of support staff for improved situational awareness
	Work areas with minimal task interruptions and visible reference material
	Clear signage and directions to assist with patient wayfinding
	Available workstations in care-team stations
	Areas for face-to-face team meetings
	Private offices accommodating simultaneous consultation and computer screen viewing
	Opportunities to socially connect with patients outside clinical encounter while maintaining flow between visits
Nurses and medical assistants	Care-team stations with areas for teams to work collaboratively or huddle
	Opportunities to socially connect with patients outside clinical encounter
	Protect patient privacy for those receiving care in-person and via phone
	Opportunities for incidental communication with providers
	Ease of finding providers via line of sight in or in nearby offices
	Reduce sound from phone calls for those nearby, such as triage call centers
Registration and check-out staff	Protect patient privacy for those receiving care in-person
	Provide adaptable workspaces that can ensure patients are viewed upon entry and during wait time

Discussion

We found distinct differences in communication patterns occurring in clinics with an OS/OS versus a PB design. These different designs created trade-offs between patient contact and privacy and between internal team communications versus communication with other clinic teams. Teams in the OS/OS clinic were concerned about being physically separated from patients, but did not experience the benefits and risks that those in PB clinics encountered from patients entering care-team stations. Colocation of providers and clinical staff in the OS/OS design allowed for more frequent face-to-face collaboration as compared to PB clinics. This personal communication, often informal, added perceived value beyond existing communication strategies in the EHR and formal in-person meetings (e.g., huddles or check-ins). In contrast, in PB clinics, providers checked in with staff by walking to the care-team station or calling. PB staff felt disconnected from their own team provider(s), particularly when communications were primarily electronic. However, in the OS/OS design, the camaraderie within teams came at the cost of perceived decreased communication with other teams in the clinic.

New models that encourage collaboration in primary care necessitate understanding the influences of clinic physical environmental design on communication patterns. Recent studies (Mundt et al., 2016; Mundt et al., 2015) have linked more face-to-face primary care team communication, such as what we found in the OS/OS clinic design, with improved patient outcomes and lower costs, whereas more electronic communication among the team was inversely associated with these beneficial outcomes (Mundt, Zakletskaia, Shoham, Tuan, & Carayon, 2015). OS/OS teams also perceived increased social interactions within their team, an important consideration given associations between decreased burnout and high team culture (Willard-Grace et al., 2014). However, our other findings indicate potential challenges with the OS/OS model. The lack of communication across OS/OS teams could challenge dissemination of clinic-wide activities, such as best practices from quality improvement (Hess, et al., 2015).

In the inpatient literature, design has been linked to increased provider satisfaction and communication between team members (Bayramzadeh & Alkazemi, 2014; Zborowsky, Bunker-Hellmich, Morelli, & O’Neill, 2010). There is a need for outpatient design models that can integrate the benefits from the two different approaches in our study. For example, having multiple alcoves throughout a clinic for provider use may satisfy the need for quiet workspaces expressed by PB providers in our study (Bayramzadeh & Alkazemi, 2014).

Additionally, preserving patient and professional privacy was an important concern. Health care professionals balance their working activities between task characteristics and the environment (Carayon et al., 2014). Providers in our study sought compensatory balance in personal office space. In in the PB clinics where providers were more reliant on private office space, they were more sensitive to privacy risks and emphasized office layout preferences. Privacy concerns related to visible screens and paperwork have been identified as issues for both providers and patients (Deshefy-Longhi, Dixon, Olsen, & Grey, 2004). In the PB model, privacy issues challenged safety effectiveness, one of the six quality aims as defined by the Institute of Medicine (Institute of Medicine Committee on Quality of Health Care in America, 2001), because the open workspaces did not adequately address the sensitivity of private health information. Patient-centered elements of design need to be incorporated that support interactions between teams and patients. Providers and staff both expressed a desire to connect with patients and sought to host patients through the clinical encounter from entrance to exit, potentially creating opportunities to build mutual respect. Data was also collected from patients in three focus groups (manuscript in progress).

This study is one of the first to evaluate professional perceptions of primary care clinic physical environments outside of the examination room using multiple cross-disciplinary methods. Focus groups allowed for concepts to be explored in-depth from a local context as confirmed and constructed during the interview with the clinic manager. However, there are some limitations to these findings. Firstly, as participants volunteered, these individuals may be highly engaged. Secondly, our findings may have limited generalizability to other settings given that the goal of qualitative research is to provide thick description of cases rather than generalizable findings. Future research could incorporate larger sample sizes, further input from non-providers, and correlate longitudinal measures of job stress with varying environmental factors across multiple groups in traditional and non-traditional office settings. Lastly, this study focused on provider and staff perceptions rather than patients. However, a prior study found that the self-rooming model of the OS/OS clinic was highly acceptable to patients and quantified the steps saved (Kamnetz, et al., 2015).

Conclusions

Our findings suggest there are important consequences to communication patterns based on primary care clinic physical environmental design. With the OS/OS design, greater communication within teams was achieved at the cost of communication across clinic. Off-stage areas provided privacy and prevented patient interruptions but led providers to feel disconnected. In contrast, PB designs accommodated informal connection with patients but left staff vulnerable to interruptions and privacy risks. How these two newer designs impact team functioning when compared to more traditional clinic layouts is unknown. When building new primary care clinics, organizations should consider aligning environmental design with desired interaction patterns.

Implications for Practice.

• Sealing off work areas may limit patient interruptions and privacy risks, but may also enhance interactions within the team sharing the same work area while limiting interactions with other teams in the clinic

• Open, shared work areas are vulnerable to privacy risks and challenge staff efficiency with patient interruptions, but communication across teams in the clinic may benefit

• Both models valued opportunities to connect with other care teams in the clinic, quiet locations near examination rooms for visit documentation, and having support staff in their line of sight

• Having team members sharing the same colocated space has benefits and challenges, such as communicating with nearby colleagues as an alternative to electronic messaging or a question interrupting a workflow