About Cottonwood Medical Clinic

The new four-story, 78,600 SF multispecialty Cottonwood Medical Clinic is located on the southwest section of The Orthopedic Specialty Hospital (TOSH) Campus in Murray, Utah. Its location, with the Wasatch Range to the east, offers breathtaking mountain views. The building is part of an overall master plan for the campus growth and development of the site. The project was designed to include capacity for future growth needs, and to link with the campus and Intermountain Healthcare as a whole. The building is flanked on the east side by newly designed open space that is shared by and creates a buffer to the neighboring Intermountain Healthcare facilities. This space is parted by an undulating pathway punctuated with a series of smaller gardens offering intimate healing environments for patients, places of respite for families, and break areas for clinical staff. Native and adaptive plant species were chosen based on aesthetics and maintenance, as well as for functional purposes—strategically placed to provide shade, windbreaks, and screening as needed. The site design provides a vehicular drive-through so that patients may access the Cottonwood Pharmacy for a convenient, one-stop-shop experience to meet their wellness needs.

Based on Intermountain Healthcare’s goals, and recognizing that operational planning is the foundation for functional design and key to creating a patient-centered environment, ZGF facilitated an approach that integrated clinical process improvements concurrent with the physical planning of the facility design. The entire design team, including the client and contractor, was integrated into the process early, and continuously, to offer recommendations and cost-effective solutions in real-time. The goal was to leverage the relevant operational planning work already completed by the client and build on it, while developing a design that is flexible and adaptable to changes in the future as healthcare continues to evolve.

A contemporary architectural expression, distinguished by a combination of brick, glass, and metal on the exterior complements the surrounding medical facilities, yet provides a unique identity for the Cottonwood Medical Clinic. The glazing and metal panel building envelope rises from a brick base, the design of which draws on the vernacular of the campus. The brick palette, with a range of clay colors, adds a warmth to the building and distinguishes it from the surrounding campus. The brick façades are further articulated with a recessed metal band in a warm charcoal mica finish to reduce the building scale in the context of the campus. At the ground level, a canopy, clad in the same metal panels used higher on the building, reaches out to the front drop-off, welcoming patients into the lobby of the clinic while offering protection from the elements. The glazing above envelops the interior concourse and patient hallways, maximizing access to daylight controlled by metal sunshades, while also preserving the dramatic mountain views.

The inspiration for the interior design came from the surrounding natural landscape—lake, desert, forest, and mountains— and the diverse colors and textures of these landscapes: aqua blue, desert gold, forest green, and sky blue. To distinguish the four levels of the building, a different color scheme was assigned to each floor. Materials, colors, and lighting elements celebrate the outdoors and were incorporated into the design to promote the health and wellness of patients, staff, and families.

A unique, but complementary, combination of wood grain, glass, and a graphic pattern are applied to each floor, in keeping with the landscape interpretations. For the flooring, rectangle carpet tiles in four different shades are mixed to create a gradient pattern to serve as a transition between the open public concourse area and the private staff work area. At each level, the concourse, while unified by an overarching wood frame, is divided into three discrete areas—affectionately referred to as the living rooms—one located at the front of each clinical pod. This a place for patients to comfortably pause after check-in and before being led into the treatment areas. Hallways, treatment areas, and living rooms have finishes that maintain a connection with each other, yet distinguish each service area while providing wayfinding cues. The combination of the striped and solid patterns, in neutral and bright colors, creates a comforting and warm environment. Physician offices are located along a corridor at the back of the clinical pods where a glass partition, obscured by a vinyl applied graphic, offers providers some privacy, while allowing borrowed light to enter into the care team area.

Planning this new multispecialty clinic for an established healthcare provider afforded an opportunity to rethink their clinical care model by implementing operational, workflow, and cultural changes within a patient-centered environment. The design provides distinct care team and patient zones. Multiple spaces are provided for “on stage” and “off stage” activities. The concept utilizes partitions to separate patient and visitor paths of travel to minimize unnecessary interruptions and help ensure patient privacy. These design and process improvements were identified early in programming to meet key target metrics and objectives, such as reducing cycle time to shorten patient visits, grouping common patient flows to share support staff across common functions, and designing performance specifications for each common patient flow.

To accommodate patients utilizing the many services offered in the Cottonwood Medical Clinic, there is surface parking around the building, as well as a drop-off driveway. Two elevators and a central stair off the main public lobby service the four levels. The stair not only encourages healthy vertical movement for those who are able, but, during shorter daylight hours, it becomes a glowing design focal point for the building’s south façade. Information and check-in areas are centralized on each floor, and all seating areas and exam rooms are sized to accommodate patients and their families.

To achieve an efficient, patient-centered solution, an integrated Lean Design approach was implemented throughout the planning process. This involved developing a cross-functional core team comprised of various specialists—physicians, nurses, medical assistants, laboratory and radiology technicians, pharmacists, social workers, dieticians, receptionists, materials management, and IT personnel—to work collaboratively with the clinic leadership, the design team, and the contractor, to create a facility focused on Intermountain Healthcare’s number one core value: do what is right for the patient.

The process integrated traditionally linear programming and schematic design phases into a consolidated, iterative effort, where proposed operational and space plans were tested, analyzed, refined, and then tested again, resulting in the alignment of the staff around future operations.

Hypothesize. Having analyzed “current state,” and with improvements in mind, the teams put forth a series of proposals regarding how care delivery could be improved.

Test. The multiple solutions and designs were put to the test. Activities were mapped and tested to understand how the proposed design would perform. Diagramming workflow and full-scale mock-ups provided an understanding of scale, distance, relationships, and process requirements. Simulation of clinical scenarios involving patients and families assisted in identifying the best options.

Evaluate. Proposals were analyzed and scored against established goals and performance criteria.

Synthesize. New and modified solutions were developed based on rigorous evaluation and study. The participants’ role during this process was to identify and test the optimal clinical processes, while the design team synthesized the work of the group to create and present informed suggestions and architectural solutions that took into consideration codes, budget, building systems, project objectives, and the overall quality of the spatial experience.

Using five, multi-day Integrated Design Events (IDEs) scheduled over five months, the client and design team collectively made operational and design decisions to achieve functional and operational outcomes in support of Intermountain Healthcare’s goals for the project. These design events were used to collaboratively harness the range of talents and insights of the team and bring the best value to the process to maximize efficiency, allowing for the most creative, flexible, and cost-effective design solutions to emerge. The following key outcomes were targeted:

• Increase efficiency
• Reduce non-patient care space
• Maximize building square footage on site and incorporate growth
• Improve patient satisfaction scores
• Improve call abandonment rates
• Reduce the number of days for an appointment
• Improve wait times

The initial planning began with the team using a Charter as a way to document decisions, boundaries, roles, and assignments for members of the various project groups. The Charter defined the core team and other resource representatives. At the conclusion of each IDE, the core team reported to the steering committee to obtain feedback and endorsement of key decisions. This helped to build consensus and confidence among all stakeholders.

The IDEs were structured to guide participants through quantitative and qualitative decisions in order to define their new operating model, and to explore how the design could best support their goals. A variety of strategies and tools were used to help clinicians and staff visualize, assess, and test future work processes. Teams tracked the “Seven Flows of Healthcare” (patients, families, staff, supplies, equipment, medications, and information) to ensure that operations were driven by Lean concepts to bring the “right elements together, in the right quantity, in the right place, at the right time” and to safely and efficiently deliver care into the future as healthcare delivery continues to change.

For this project, five IDEs were planned, as outlined below.

IDEs 1 and 2 were focused on “current state” activities to provide everyone with a better understanding of the existing operations and culture. Each specialty completed an internal evaluation of its “current state,” including spaghetti diagrams of their existing clinic space, tracking all of the flows of healthcare to visually identify what was working and where there were opportunities for improvement. This information was then presented at IDE 1. This step was essential to aligning the group and setting the foundation for making changes and improvements. The ideas that resulted were fully explored, ultimately leading to how processes would change or be modified in the future. By the conclusion of IDE 2, “future state” was identified and these concepts were tested in IDE 3. One of the biggest process improvement measures that the Cottonwood Medical Clinic wanted to implement was to bring services to the patient. Cycle time was built into the clinic visit, space to perform this laboratory function was built into the care team space, and staff members were trained in standard work to perform the task.

IDEs 2 and 3 were focused on further developing and testing new ways of doing things in the “future state.” Table-top exercises and mock-ups allowed clinical staff to simulate flow, transport, steps, and procedures. Modifications using a physical mock-up to test various options informed the size and placement of rooms. For the Cottonwood Medical Clinic, half of one clinic pod or module was built to be tested. This included all of the major spaces that would be replicated numerous times in the building, such as exam rooms, procedure rooms, consult rooms, and a centralized care team work area. This allowed the opportunity for the participants to experience these spaces in real-time in order to confirm adjacencies and sizes by those who would ultimately be the users of the facility.

At IDEs 3 and 4, analysis continued as favored solutions were tested, refined, and tested again—resulting in a confirmation of the programmatic elements that were at the right size, and with the proper adjacencies to support “future state” functions. Evaluation criteria were again applied to ensure that the proposed “future state” satisfied the goals established by the core team.

IDEs 4 and 5 provided the opportunity to further develop the plan, including all of the support rooms, and integrating the consultant requirements and detailed equipment specifications. The Cottonwood Medical Clinic program had a few specialty areas, such as an Urgent Care, which were also mocked up separately from the typical clinic module that would be repeated across all specialties. This allowed the client the opportunity to make some slight deviations to the module as needed. The client also took the opportunity to tape off distances between different areas to verify that the number of steps would not be excessive and to outfit certain spaces with equipment to confirm configurations.

The work that was accomplished at these IDEs shaped new ways to deliver clinical services with a built environment that supports improved processes for Intermountain Healthcare’s patients and families at the new Cottonwood Medical Clinic. Once IDEs were complete, a final report was created to summarize the outcome of the events and provide a roadmap for staff to continue their work in preparing for the transition.

The following Guiding Principles, Model of Service Care Delivery, and Performance Criteria were developed and used to validate all decisions that were made throughout the IDE process. The Guiding Principles promoted a shared vision, with the end result reflecting a consistency in the design at every level.

GUIDING PRINCIPLES

• The patient is always first.
• Achieve extraordinary clinical outcomes.
• Design space for efficient use of planned Electronic Medical Record (EMR) implementation, for now and in the future.
• Develop greater access points in the central Utah valley to primary and subspecialty care.
• Physically integrate clinics and services to optimize operational and clinical integration.
• Improve efficiency and decrease waste.
• Create adjacency to TOSH Campus services and embody campus design.
• Provide new, attractive, functional spaces.
• Integrate care teams.
• Improve on Intermountain Healthcare’s processes (supply chain, registration, etc.).
• Create attractive, patient engaging, functional space that supports coordination of care and operational efficiencies.
• Create adjacencies with like specialties / functions.

MODEL OF SERVICE CARE DELIVERY

• Patients will check in at a centralized station located on each floor. Staff at reception will not be responsible for answering phones, providing devoted attention on the check-in activity.
• Medical assistants will perform standard rooming activities and Intake will be performed in exam rooms.
• Providers will perform standard work in both exam and procedure areas. Supplies, computers, and everything needed will be located in the core team area or off-stage in support locations. Laboratory results may be reported before the patient exam is completed.
• Services will be brought to the patient. Blood draw will be performed during the patient exam, with staff dedicated to this function. A runner will be identified to deliver specimens to the main floor laboratory.
• Standard pods with standard exam / procedure rooms and an on-stage / off-stage circulation concept, separating staff and patients along with integrated core team spaces to enhance communication and flow, will support caregiving.
• Each pod will contain a consult room for care managers, and mental health and other specialists to meet with patients and families.
• Separate call centers (Patient Services Center) will be located on each floor to free up patient service representatives for patient check-in and to enhance patient flow.

PERFORMANCE CRITERIA

• Improved patient privacy
• Enhanced team integration
• Efficient and Lean flow of staff and materials (what / where / when needed)
• Comfortable, aesthetically pleasing environment that integrates Evidence-Based Design principles
• Intuitive wayfinding that integrates Evidence-Based Design principles
• Enhanced ability to manage population health through a team-based approach

Some of the outcomes of the Lean process led to project features that also minimize environmental impact. Ultimately, the systems put in place were implemented because they were found to improve patient comfort, a primary client objective. The specific sustainability strategies for the project include:

• A site design that promotes pedestrian and bicycle access by providing a bicycle storage area and tree-lined walkways to assure a safe and secure path.
• Implementation of a subsurface stormwater management system and pervious landscape areas that mitigate stormwater runoff.
• Integration of abundant natural light with daylighting controls that reduce the energy use in the building. The lights are all on occupancy sensors, and overrides in the spaces allow users to turn off the light when there is adequate natural light. All lighting uses low-energy LED fixtures.
• Permanent shading devices and automatically actuated shades were used to reduce solar gains during the warmer seasons.
• Use of furnishings and finishes with low-VOC’s.
• Specification of low-flow fixtures to reduce water use.
• Utilization of high-performance exterior glazing and reflective roofing to reduce heat gain.
• Use of Forest Stewardship Council certified wood and regional materials, wherever possible.