According to Nancy Shepherd, partner at Carvel & Helm, a key priority for St. John’s Atlantic Oral Surgery and Implant Centre entailed providing a state-of-the-art facility capable of attracting top level professionals in a highly competitive market. Her focus, therefore, included creating a hospitality-like patient experience that included alleviating wait-room anxiety.
Prior to settling on an engaging aesthetic, a clear “functional assessment” of layout and workflow needs was conducted, including reducing wait times. The average patient is an adult who will experience longer stays and require an escort because of sedation. Previously, patients recovered in the treatment chair, which delayed starting the next procedure. In response, the new centre is divided into three defined spaces: a public area (reception/waiting); semi-public zone (consultation/diagnostic rooms); and a completely secure treatment area with a separate recovery area. A secondary entrance from the elevator lobby provides escorts access to the recovery area without going through the surgery zone as well as providing a discrete exit for the patient, unseen by those nervously awaiting surgery.
The generous waiting area, awash with abundant natural light, boasts large lounge pieces (such as Bevi from Steelcase) to improve comfort for longer stays. Unique, baffled light fixtures mediate noise. A dedicated escort wait area includes a beverage centre, television and digital connections enabling escorts to work while waiting.
Shepherd wanted a crisp medical feel. “It is a clinical environment,” she says, “and we wanted to keep that sense of sterility [but] without sacrificing comfort.” To introduce comfort, curving wood grain walls link zones and add an organic, biophilic-sense by “mimicking natural textures and materials and introducing the curved profiles you see in nature.”
Q&A: Nancy Shepherd, partner, Carvel & Helm
What were the key elements of the project brief that the client brought to you?
There were a couple of priorities. The first was patient experience. Patient care must be well in hand because the doctors recognize that this experience needs to be more attractive for an implant clinic that offers elective procedures. When your service is elective in nature for which people are spending their own money for an expensive treatment, the quality of the experience must be beyond what you might get out of a standard dental clinic. Thus, patient care is obviously paramount. Second, they were planning on growing their previous clinic which had been a single doctor. As a result of the growth, we had to make sure that they could accommodate the increase to three surgeons.
In the older clinic, patients would recover in the operating room. By providing a separate recovery area [in the new clinic], it actually decreased the patient wait times because after treatment they were able to move the patient to a more pleasant and separate recovery [00:03:04] area with a dedicated nurse to oversee and provide care. The surgeon is now freed up to take a new patient in the operating room. So it now really works both from the patient’s perspective as well as from an operational efficiency perspective.
In addition, there was a real interest in providing a seminar room for professional development. By creating this expanded practice they wanted a benchmark facility with the ability to share with their colleagues. They can now do video conferencing case studies. There is a regular study group within the broad dental industry with just [dental] surgeons. However, dentists, oral surgeons and anyone else involved, such as referring doctors, can come together to review and study cases. One of the treatment rooms is equipped with video conferencing so it is essentially a live surgical theatre where, with patient consent, procedures can be broadcast as part of a continuing education program.
These three things, patient experience [with dedicated recovery area], growth capacity without negatively impacting efficiency and the introduction of professional development as an oral surgery facility, were different requirements than what you would find in a more standard dental practice.
There is certainly less focus on being a family care practice. Thus, the average patient is an adult and this points [to mandating] a more sophisticated space. There is also a different level of expectation given the longer duration of a patient’s stay. Typically, they require an escort such as a family member. As a result, the waiting room is fairly large in size because there are people not actually receiving treatment. They are present because a patient may be sedated and it is required that they be escorted. So the waiting room [has a dedicated escort area] with a beverage centre and a TV because an escort] could be there long enough to watch a movie, for example. Power is provided in a lot of the furniture so people can work while they wait.
There is a full sterilization station as well as a diagnostic centre and a dedicated nurses’ station. [Although] there is also one standard dental treatment room, the actual operation rooms are larger [than stand treatment rooms] and there is definitely a higher level of detail in terms of the equipment coordination.
You talk in your documentation about a “functional environment” being a key objective. Just how have you designed the clinic to be an environment that is functional?
It had a lot to do with the flow throughout the space in order to minimize any disruption from one space to another. There are very defined public areas which include reception and waiting. There is then a semi-public zone directly off of that which includes a consultation room and a diagnostic area. The actual operation rooms now become completely private in a secure zone. In the past, escorts would have been permitted there while the patient was recovering. In the new layout, public access to secure areas is minimized and the operation area is only surgeon, nurse and patient until you move out to the recovery area. A secondary entrance is provided for escorts to access the recovery area without having to go through the operation zone.
The millwork and equipment coordination was at a very detailed level [such as] measuring instruments and the size of tanks with everything having its own [designated] place right down to the gloves. Sterilization being such a huge concern, all of that required quite a level of effort in terms of functional design. The only other thing I would mention is the acoustics of the space. Again, this goes back to the patient experience. We provided acoustic baffle [light fixtures] and really tried to be cognizant of balancing the openness of the waiting area with the need to provide the administration staff with enough privacy to perform their work. We didn’t want any of the connectivity to interfere with how they perform their tasks. We wanted to try to control the traffic of patients and staff as they go through this [treatment] process.
Given all the elements of the client’s brief, etc. what do you see as the key elements in your design response that you brought to realizing the centre?
I think our biggest contribution was augmenting what I will call the waiting room experience. Unfortunately, it can be where patients spend the majority of their time. So, although there was a mandate to decrease the patient wait times, we focused on ensuring any time [spent in that space] would be really comfortable with an almost hospitality feel. We really tried to minimize the clinical atmosphere to alleviate anxiety levels for someone about to undergo surgery. That was key for the patient experience.
From an operational perspective, it was about creating these really defined zones. This is a work environment as well for the administrative and medical staff. Providing all of the necessary amenities for them to work as well as providing a dedicated staff kitchen, nurse station and dictation area. All of that was to ensure there was the necessary support in place within the facility for all the various tasks that they perform.
Leading into the next question, the windows to the exterior play a role in the space as a working environment. Although the patients are for the most part sedated in the operating room, the staffers certainly are not. [The windows] provide a pleasant experience to staff giving them access to natural Light. You see that typically in the clinic’s office environments but it is optional in the treatment rooms. The windows have roller shades with 3% openness; thus, there is some manipulation ability there, but it certainly adds to the overall feel of that space having access to natural light.
We know, based on evidence-based medicine, that access to light and exterior views is a key element to recovery. What about your use of wood; are the curved walls in the clinic walnut?
We used a wood grain wallcovering. It is not a genuine veneer, it’s a printed wood tone which is also true for the flooring as well. We wanted the wood grain as well as the concrete-like flooring to indicate natural materials where we could. The curving of some of the walls also works to ensure access in the event there was a need to use a stretcher in the space. [Curved walls] are also great for durability being less prone to damage.
But I think the curve also added a bit of an organic sense to that space; and, again opened it up a little bit, particularly in the public areas. We continued the [curves] even down into the private zone along the surgical suites and even within the public washroom. We managed to maintain the turning radius of the curved wall by making the washroom slightly larger as we felt it was important to have that consistent throughout the space.
We adopted a kind of biophilic approach to the design, mimicking natural textures and materials and introducing the curved profiles you see in nature. Otherwise, the design is balanced with a lot of just crisp white. It is a clinical environment and we wanted to keep that sense of sterility to a degree without sacrificing comfort. The flooring in the public areas is wood grain vinyl from the Tandus Contour Antique Wood Series. In the treatment area, the floor is from Tandus Modern Stone series with a concrete look.
In your design statement you write: “managing circulation throughout the clinic was critical to establishing adjacencies and defining the patient experience.” Can you give me a couple of examples of how your design responded to this requirement?
Something I didn’t initially consider was brought to our attention by the client. It was important that we minimize any visual connectivity between a patient that has just undergone a surgery and those who are still awaiting a procedure. It can be intimidating or off-putting for those waiting to go in. That was something we had to consider when we were looking at how the [patient] is brought into the operation zone and how [the patient] is led into their recovery. We provided a secondary exit that leads the [patient] directly back out into the elevator lobby. [The patient’s] checkout is all completed prior. A certain level of ignorance is bliss is maintained for those still waiting.
A staff entry is also available directly off the elevator lobby into the operations area to minimize any traffic disruptions in the administrative and waiting room areas. The only people going into these latter areas are patients. [In addition] the waiting room is large enough so that you don’t walk in and see 20 people and think, “Oh God, I’ll be here all day,” because there is a separated escort lounge. Additionally, the large lounge pieces [in the wait and escort areas] are scaled to accommodate longer stays [Bevi from Steelcase].
Other than that, I think it was just really about maintaining the separation of public and private zones. We definitely took advantage of the full floor plate and the ability to have staff access from and patient exit to the elevator lobby and stairwell.