By Garrett Ludwig
Consider for a moment that just about anyone with opposable thumbs and fine-motor skills is capable of performing an amalgam restoration. Most people would affirm that postulate. As a designer, I attended Columbia University to learn the fundamentals of four-handed dentistry in an effort to enhance my proficiency as a dental office design specialist. During that education, I excavated a first molar on a mannequin for an MOD, then filled and deftly (in my opinion) carved the compound. I would expect that, with a little practice, I could produce a restoration that would be visually and occlusally perfect. However, without understanding human anatomy, physiology, disease pathology, and the proper treatment of caries, the patient would be at serious risk. Furthermore, the restoration would probably fail in the absence of prescribed technique. The same outcome can be expected when designing and building a dental office without professional guidance.
It never ceases to amaze me that dental professionals - who know and understand that there is no substitute for knowledge, experience, and skill - frequently venture into such an extremely complex undertaking as dental office design with reckless abandon. The fact is that design is a “pay now or pay later” business. Invariably, those who are intent on saving money by foregoing professional guidance ultimately pay substantially more throughout the life of their project, and reap a lesser return on their investment. Unfortunately, most don’t realize it until it’s too late, and they have to live with the result or pay exorbitant professional fees in an effort to salvage their investment.
I share them with the hope that this insight might avert a bad investment.
1. QUANTIFY BEFORE YOU QUALIFY: IT’S THE “MEASURE TWICE, CUT ONCE” APPROACH TO ESTABLISHING SPATIAL NEEDS.
Based on observation and personal experience, it is apparent to me that the process of evaluating the quantity of space needed to support the efficient function of a dental practice is at best challenging. In most cases, I have found that do-it-yourselfers forego or trivialize the pragmatic process of quantifying the cumulative needs for each area and function of the office. The following are common judgments and oversights that result in space insufficiency.
A. The two most common barometers that are used to establish square footage needs are industry statistics and feedback from professional colleagues. Although both merit consideration, they are often misleading. With the former, you may hear the axiom that seating in the waiting area should be based on the quantity of treatment and hygiene rooms. To profess that unequivocally implies an assumption that a general dentist with a family practice would have the same needs as a generalist who concentrates on cosmetic care. Also, since no two practices are equipped, staffed, and managed identically, the latter can be equally misleading when establishing the need for space.
B. Accommodation for practice growth is commonly overlooked or short-changed. For example, many choose to add one treatment room for an associate that may join the practice. However, few consider the fact that a single room would limit the production capacity for that individual, and would result in a diminished potential for that person’s growth. As a result, the opportunity to join the practice is less enticing to potential associates.
C. Although most practitioners make reasonable, room-by-room calculations for space, I frequently hear the statement, “We are currently working in a 1,200 square foot space. Therefore, 2,200 square feet should suffice.” Theoretically, that assumption seems plausible. However, many things must be acknowledged, including changes in building regulations, ADA and HIPAA compliances, growth, as well as many of the conditions referenced above. It is truly remarkable how quickly 1,000 square feet can be consumed by “essentials.”
D. In addition to the insufficiencies that are often calculated for the respective areas within the confines of the suite, there are three areas that are consistently overlooked: storage, wall thicknesses, and passage space. Despite the fact that the most common complaint from dental personnel is that there isn’t enough storage space, it is the most frequently overlooked spatial accommodation. The wall thicknesses and passageway space consumption are visually more subtle. Yet they typically have an even greater impact when ignored.
With regard to the passageways, the more complex the space, the greater the need for passageway space. So, in most cases, if passageway space has been considered in the overall calculations, the likelihood that an adequate amount of space has been allocated is slim. Additionally, the consideration that a partition is only four or five inches thick evokes the sense that very little space will be needed for those separations. The fact is that even a small suite may consume 100 to 200 square feet with partitions alone.
E. Less is not more. I frequently encounter practitioners who base their selection of a space on the cost per square foot, rather than the potential for earned revenue, since they are allegedly “throwing the rent money away.” The perception is that, by reducing overhead, the net revenue will increase. That’s another illusion that is slanted by unfounded statistics. “The practice overhead should be...” Nothing could be further from the truth. Dentistry, like any other business, will thrive on its enhanced capacity to generate revenue.
In addition to heightening function, space creates a feeling of comfort and an image of success. That’s a point worthy of consideration when shopping at Saks or Nordstrom .... and CVS. Your perception of those businesses is likely to be the equivalent of your patients’ perception of your practice.
2. PROFESSIONAL GUIDANCE IS HIGHLY RECOMMENDED WHEN MAKING A LAND PURCHASE
All too often building sites are determined to be distinctly challenging and/or impossible to develop after the purchase has been made. Although there are many more, the following are common considerations that are most often overlooked by an inexperienced investor. Point to ponder: I have witnessed many practitioners who have spent more time researching the purchase of an automobile than they did when investing in a land purchase.
A. Health-care facilities require more parking than does general business. As a result, it is common to find that the intended size of the building has to be reduced to accommodate parking.
B. In a similar context, zoning regulations require definitive building setbacks. Not only does this often impact the size of the building, but the placement of the building, as well. The vision of constructing a dynamic structure with great curb appeal can be quickly dashed when it is determined that the building must be located beyond the line of sight from the roadway as a result of building setbacks, laneways, screening, and the imposed limitations regarding the allowable amount of paved surface.
C. Regardless of the longevity of an undisturbed parcel of land, a soil test should be considered. It is not uncommon to determine that a site has a high water table, thereby diminishing or complicating the development of the site. Similarly, the site could have been used for dumping of incompatible materials or hazardous waste before environmental records were kept. The remedies for such conditions can be very costly.
D. Clear view of the building aside, any marketing-savvy practitioner is going to want their signage to be highly visible. Although zoning regulations vary from town to town, almost all towns regulate the size, style, and placement of signage, and typically define the size by square footage. So, for example, if a two-sided sign is proposed, and the regulations stipulate a maximum square footage of twelve feet, the likelihood is that you would only be allowed six square feet per side, or a sign measuring approximately two feet by three feet. When you consider borders and logos, there would be very little space left for text.
3. PROFESSIONAL GUIDANCE IS HIGHLY RECOMMENDED WHEN EVALUATING A LEASED SPACE FOR USE AS A DENTAL OFFICE**
The lack of review by a trained eye may result in the discovery of many physical encumbrances and restrictive, contractual covenants. The following are a few of those that I have encountered most frequently:
A. First and foremost, the majority of property owners list the square footage of a suite as “leaseable,” in accordance with BOMA (Building Owners and Managers Association); that includes one half the thickness of the perimeter walls. This is frequently confused by the lessee as “useable” space. Depending on the overall size of the space and the thickness of the perimeter walls, the “useable” space could measure a few hundred square feet less than the quantity proposed. That calculation grows with a flush glazed “curtain wall,” since measurements are often made to the glass surface on exterior walls. Flush glazing is as it sounds. The mitigating factor is that the “leaseable” measurement can increase by the remaining thickness of the exterior wall. We have encountered walls as thick as 24 inches.
B. The area inside the perimeter space may be further compromised by the existence of utility chases, elevator hoistways, roof drains, structural members, roof access ladder, low ceilings, etc. It may also be necessary to provide space for a water heater, dental utilities, and mechanical system storage (HVAC) within the suite. Each of these represents an additional loss in useable space.
C. The useable space may be further diminished by the need for an internal vestibule or airlock to protect the waiting area from harsh weather in a facility that has direct access to the exterior. Not only will the vestibule encroach on the useable space; it will also impact the use of the space from the standpoint of functional design.
D. Signage is often limited in a leased space, particularly in professional office buildings as well as some retail facilities. This isn’t necessarily a “deal breaker,” since some locations are, in and of themselves, distinctive landmarks, and are identifiable and easily accessed. However, visibility and accessibility must be considered as components of the practice marketing program, regardless of the location.
4. IF THE DO-IT-YOURSELF APPROACH TRULY SAVES MONEY AND PRODUCES A QUALITY PRODUCT, ONE WOULD ASSUME THAT ENDODONTISTS, PERIODONTISTS, AND ORAL SURGEONS WOULD BE SERVING A VERY SMALL PATIENT POPULATION.
When it comes to construction, I consider myself to be an inveterate “do-it-yourselfer,” having worked in the building trades for most of my life. Globally, I would comfortably state that I have completed most tasks successfully. However, I have also experienced the need to call in a professional when an unexpected problem arose. In each of those cases, it became apparent that, had I engaged the services of these skilled individuals from the beginning, the dilemma would not have arisen or would have been readily addressed at a modest cost and in full compliance with building regulations. Most importantly, I would have saved my valuable time to generate revenue in my area of expertise.
The perception of cost savings by eliminating a general contractor, construction manager, project manager, or superintendent is truly illusory. In short, a dentist in a restorative practice can generate far more revenue per hour than it would cost to hire the necessary personnel to perform their respective tasks, and those persons know the complexities of the building trades as well as the practitioner knows dentistry. Therefore, if logic prevails, it makes perfect sense to delegate the responsibilities of design, development, and supervision to those who are qualified to provide those services.
A. Bid proposals and construction contracts are a challenge for all of us who work in the field. Beyond the primary considerations of cost, time frame of completion, and the inclusiveness of all trades and services, there are many more subtle factors that will impact our recommendations. To assume that decision-making process in the absence of an inherent knowledge of the construction industry is, in my opinion, financial suicide.
B. I spend a great deal of time each day on the telephone and computer (e-mails, faxes, transmittals) managing each project. Whether it’s a matter of value engineering, discovery of a field condition, or third-party coordination of services, there is an ongoing stream of project management activity that must be addressed expediently and must be thoroughly documented, just like dentistry. For a practicing dentist to respond in a timely manner is challenging, at best. Documentation of any sort is even less likely to take place. In the meantime, the “clock is ticking” and you can bet that the contractor has documented the communication, particularly if it involves a change order that may create an added cost.
C. If one were to assume, hypothetically, that all inquiries were simple and required a brief response, the process would still be challenging. The fact is that many of these inquiries necessitate some level of research. That effort demands three things: the time to perform the task, the knowledge of where to look for the comparative data, and the knowledge to differentiate the risks and benefits of each.
5. FORM, FUNCTION, AND FLOW ARE MORE THAN JUST BUZZWORDS FOR DESIGN. THEY EQUATE TO THE ENHANCEMENT OF PROFESSIONAL IMAGE, EFFICIENCY, PRODUCTIVITY, AND, ULTIMATELY, PROFITABILITY.
Convenience, comfort, atmosphere, and image are all amenities that we seek when selecting a restaurant or automobile. Let’s be honest, that fully-equipped Camry would probably suffice as better-than-adequate transportation. However, for a “modest” difference in cost, the C-Class Mercedes (or better) seems to lead the pack with professionals. In the same context, you can’t find a better meal than one prepared at Momma’s Diner. Nevertheless, the starched white tablecloths, impeccable service, and great ambience are what inspire long lines at Le Diner de Maman. And, of course, as a preferred patron, the words, “Dr. Jones, your table is ready,” allow you to whisk past the masses who wait patiently to be acknowledged. Even an average meal tastes better when it is served by attentive personnel in a warm and relaxing environment.
The fact is, if there is any group of people that deserves to be treated to the very amenities that we all seek when selecting a provider of superior services, it is your patients. Since it is superior service that you are offering, preferential treatment is truly in order for those who have selected you as their dental professional.
With that thought in mind, consider a distinctly tangible example of the “service” philosophy as it equates to investment: Assuming that you are considering offering refreshments to your patients, you might weigh the image presented by a Poland Springs bubbler to that of an attractive cabinet and counter that houses an inline filter/chiller/water heater. They each provide filtered hot and cold water. However, the latter is dispensed by a stainless spigot into a glass bowl.
As a consumer, which would you prefer? An unattractive, commercial-looking plastic dispenser or a classy-looking refreshment center? Of course, the classy system would win hands-down. So, why do I see so many commercial dispensers in dental offices? Clearly it is expense.
So, let’s compare costs. The Poland Springs dispenser will cost a minimum of $35 each month. Over a five-year period, the out-of-pocket expense would be $2,100. That does not include the valuable and costly storage space that the bottles consume (or clutter) or the labor involved to change the five-gallon (40 pound) jugs. On the other hand, the one-time cost for the built-in system might be $1,800. That would include: cabinet, counter, bowl, spigot, water heater, water chiller, water filter, and drain. The labor consists of restocking cups and an annual filter change. Comfort, convenience, and enhanced esthetics – all for a lesser cost. Imagine that!
As is the case with the refreshment center, the value of each element in the overall investment in a new physical plant typically outweighs the costs associated with the inclusion of the respective design efficiencies. I have included a few other areas that are often shortchanged due to a misperception that the expense would exceed the value.
A. There is no question that efficient design reduces task-related labor. For example, consider the expense of the labor that’s involved to process a wet film or phosphor plate in comparison to the time it takes to process a digital X-ray. No contest! Distractions aside, the time expended and the cost associated with the former account for an extraordinary and cumulative cost. Consider the fact that the investment in any adjunct that will enhance efficiency is worthy of consideration, since labor is a variable, ongoing expense that increases on a periodic basis. So, whether it’s a clinical skill or administrative task, good design maximizes the functionality and productivity of each support staff member, as well as your bottom line.
B. The optimized juxtaposition of support services reduces job-related stress, increases efficiency, and enhances revenue production. Consider the last time you attempted to do a home repair and had to retrieve the necessary parts at a big box retail outlet. By the time you had defined and located the parts, you were likely to have toured the entire 40,000 square foot facility, and were already exhausted from the stress of the venture before you even started the project. If you equate that experience to your own services, it stands to reason that all support services be positioned in an ergonomic and logical sequence. Since most people are intellectually aware of the value associated with this effort, it amazes me how few invest the time and effort to maximize their efficiency.
C. Although there are several means by which HIPAA compliance can be achieved, many practitioners overlook these critical measures when planning areas for private communication. Among the methods are: separation of “public” space from “private” space by barrier (partition, door, glazing); separation of “public” space from “private” space with space (extended distance between private and public areas); maximization of acoustical surfaces (carpet, wall coverings, ceiling tiles); distortion or masking of communications (introduction of “white noise,” e.g., moving water, music, sound machine). HIPAA regulations may not be proactively enforced. However, a complaint is likely to result in financial penalties, as well as daunting accommodations after the fact.
D. Good design is also an instrument of “people management.” That’s essentially what professional designers do – manage the movement of people within a space. Beyond operational functionality, the accommodation of comfort and convenience makes a patient’s experience in a professional office pleasurable.
Consider the last time you dealt with a large corporation (e.g., insurance company) or municipal agency (e.g., motor vehicle department). What should have been accomplished in five minutes probably took an hour and involved several people. It’s simply exhausting.
To avoid this experience in your own office, it is essential that the work environment be planned pragmatically to assure the effortless administration of patient services. In addition to the fluid transition that the patient experiences moving from greeting to departure, they also are comforted by witnessing that same synergy in your office operations. These accommodations are certain to project an image of professionalism and will assuredly produce tangible results. Again, most people understand the tenets of this theory. Those who apply it benefit by it. Those who don’t, suffer the consequences of it. Unfortunately, I have witnessed enough of the latter to make this issue noteworthy.
** Above and beyond the physical and developmental concerns, the language and terms of a lease can be truly significant. However, they are commonly negotiable. The fee to have a lease reviewed and negotiated by a specialist, whose sole responsibility is lease negotiation, is truly worth the investment.
Garrett Ludwig founded Diversified Design Technologies Inc. in 1971. The company has specialized in the design and construction of private-practice, health-care facilities since 1975. During that time, he has designed more than 300,000 square feet of professional office space. He has a U.S. patent on his emergency services “crash cart” design. Ludwig has shared his experience in dental office design in numerous trade publications, and continues to lecture on the subject throughout the United States. He can be reached at (800) 622-5563 and [email protected]. Visit his Web site at www.profitbydesign.us.
By Garrett Ludwig