1. Theory to Practice

2. Physician Practices have Evolved 1990 2015 Large Group 20 500 Structure Sole Proprietor/Employed Partnership/ P.C. Average loss per employed provider today = $176,463

3. The Facilities Reflected the Practice Model of the Day Practice 1 Practice 2 Practice 3 Practice 4 Single Building Multiple Buildings

4. Separate Practices ■ Separate windowless Waiting Areas ■ Multiple Reception/Check-In/Check Out Staff ■ Underutilized exam rooms ■ Practice-specific exam rooms ■ 1,400 building gross square feet/provider

5. Some Numbers… ■ 220,000 Population of Greater Nashua, NH ■ 70,000 Patients served by D-H Nashua ■ 225,000 Visits per year ■ $115M Annual Revenues ■ 90 Physicians and Associate Providers ■ 400 Full and Part Time Staff

6. Included groups  Internal Medicine  Family Medicine  Pediatrics  Gastroenterology  General Surgery  Orthopedics  Podiatry  Occupational Medicine  Physical Therapy  Cardiology  Obstetrics  Gynecology  Dermatology 90 Providers

7. Other components  Urgent Care  Imaging with CT/MRI  Medical Oncology  Endoscopy  Allergy Clinic  Administration  Support

8. A New Practice Model Consolidated Location Greater efficiency and collegiality through consolidation of practices/buildings. Medical Home Model A primary care team, led by the physician, working collaboratively to address the acute, chronic and preventative needs of patients. Multi-Disciplinary Practice Patient and staff benefits of placing primary care and specialists into a single building.

9. A Remarkable Project A completely re-engineered approach From the parking lot to the bathrooms, how can we make this the best possible process? A physician champion Leadership was able to foster creativity in an entire organization and drive consensus.

10. Tools of Communication The Blog

11. Dartmouth-Hitchcock Goals Macro ■ Improve Provider efficiency ■ Improve the staff/provider experience ■ Improve the patient experience

12. Dartmouth-Hitchcock Responses Universal Exam Room throughout ■ Avoids constant renovation and allows exams to be used by all Exam rooms are not proprietary ■ Requires fewer exam rooms No hardwall divisions between practice types ■ Allows sharing of exam rooms and promotes collegiality No hardwall physician offices ■ Providers have both on-stage and off-stage workspaces

13. Floor Plan Diagrammatic Layout for Modular Planning Design Concept

14. Floor Plan Diagrammatic Layout for Modular Planning Design Concept

15. Level 2

17. Typical Room Layout

18. Internal Shared Workspace

21. Admitting

22. Level 3

23. Level 4

24. Level 1

25. Infusion

26. Ground Floor

27. morrisswitzer environments for health Site Plan

31. Interior Stairs

32. Ceiling Detail

33. The Results ■ DH-Nashua now sees 30% more patients with the same staffing ■ Building Gross per Provider was approx. 950sf ■ The building and site were constructed for $223/sf ■ Patient, provider and staff satisfaction are up dramatically

34. Top 4 Differences from Benchmark EMPOWERMENT: It’s okay to challenge the way we currently do things. WORKING ENVIRONMENT: Employees are treated with respect here, regardless of their job. LEADERSHIP: This organization’s senior leaders have a well-formulated strategy for the present. SUPERVISION: My supervisor encourages us to continually improve our performance. above average above average above average above average

36. Bill Repichowskyj, AIA Partner, Director of Design MorrisSwitzer morrisswitzer.com | 888.781.8441 wrepichowskyj@morrisswitzer.com thank you Christine A. Schon, MPA, FACMPE VP Community Group Practices Dartmouth-Hitchcock hitchcock.org | 603.577.4000 christine.a.schon@hitchcock.org Kimberly N. Montague, AIA, EDAC, LEED BD+C Manager, Healthcare A+D Herman Miller hermanmiller.com | 248.880.9851 kimberly_montague@hermanmiller.com