4630.1

APPENDIX 14

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FOREWORD

These Physical Guidelines have been prepared

principally to give HUD Field Office

personnel and sponsor\'s architects general

information about space and equipment needs

in group practice facilities. In certain

clearly defined instances, standards which

must be followed are also included.

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4630.1

APPENDIX 14

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TABLE OF CONTENTS

Paragraph Page

PHYSICAL GUIDELINES

FOR

GROUP PRACTICE FACILITIES

1-1. Building Accessibility For The Handicapped 1-1

1-2. Administrative Areas 1-1

1-3. Patient Examination And Treatment Areas 1-1

1-4. Supporting Service Areas 1-3

1-5. Areas For Other Specialists 1-5

1-6. Special Transmission 1-6

1-7. Equipment 1-9

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4/73 Page 2

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4630.1

APPENDIX 14

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1-1. BUILDING ACCESSIBILITY FOR THE HANDICAPPED. The building should

conform to \"United States of America Standards Institute\"

publication A117.1-1961 \"Making Buildings Usable by, and Accessible

to, the Physically Handicapped.\"

1-2. ADMINISTRATION AREAS. Adequate space should be provided for

patient reception, waiting, and admitting procedures. The

business manager\'s office, business records office, patient billing

area, and telephone and toilet facilities should be located close

to the waiting space. The extent of the administrative service

in a central location will depend on the organization of the

facility. Since the patients\' initial impressions of the clinic

is formed in the reception area, a cheerful and attractive use

of space and furnishings is desirable. Good reading light and

comfortable seating are needed. In large facilities, the

administrative area may also provide for a doctors\' lounge,

conference room, library, isolation of patients suspected of being

infectious and where applicable, a waiting area for small children.

a\. Centralized Medical Records. Space shall be provided for

centralized medical records. This area is usually located

within the administrative area or adjoining it. Medical

records for all patients of the clinic are kept here.

b\. Medical Record Librarian. In larger facilities, work space

for a medical record librarian should also be provided. It

may also be necessary to provide space and equipment for

microfilming medical records.

1-3. PATIENT EXAMINATION AND TREATMENT AREAS. Most group practice

facilities, which provide for practitioners such as the internist,

the surgeon, the obstetrician-gynecologist, the pediatrician, and

the orthopedist require certain similar areas: consultation

rooms, examination rooms, treatment rooms, and recovery rooms.

Various combinations of these rooms are often desirable, such as

consulation-examination room, or a treatment-recovery room.

a\. Consultation Room. A typical consultation room should be

large enough for a full-size physician\'s desk and comfortable

chairs for two or three people. Space for bookcases and one

or more file cabinets should also be provided.

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4630.1

APPENDIX 14

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(1-3) b. Examination Room. Adjacent to the consultation room and

usually accessible directly from it should be an examination

room. An examination room may be required on each side of

one consultation room. The examination room should be large

enough for a full-size adjustable examining table, an

instrument supply cabinet, a small instrument table, a small

desk or wall-hung writing surface for the physician, and one or

two straight chairs. A good examining light should also be

provided. A small curtained-off space in a corner of the

room for patients to undress is desirable, and a patient

toilet should be easily accessible.

c\. Recovery Room. A recovery room is needed in most clinics.

It may also be used for tests and treatments such as injections

and EKG\'s. Space should be provided for a bed, equipment,

an instrument and supply cabinet, and a chair.

d\. Surgery Clinic. In a clinic where minor surgery is

contemplated, a small surgery room with a small dressing room

adjoining should be provided. This room requires an

operating table instead of an examining table, portable

examining light, and instorement table. If surgical procedures

requiring the use of explosive gases are contemplated,

compliance with NFPA No. 6, Code for the Use of Flammable

Anesthetics, is required.

e\. Dental Examination. Dental examination and diagnosis may

require one or more operatories. While fully equipped

operatory, such as one described in the next section,

entitled \"Dental Operatories\" is not always considered

necessary, it is sometimes desirable in order to provide

greater flexibility in use. Taking X-rays is part of the

examination and diagnosis procedure and requires that

appropriate radiology equipment be located adjacent to or as

close as possible to the operating room. For a small dental

facility, X-rays may be taken in the dental operatory, but

particular care must be given to locating the equipment to

provide proper shielding from gamma and X-rays. In larger

facilities, a separate radiology section as described under

\"Dental X-ray Service\" should be used.

f\. Dental Operatories. A dental operatory varies in size from

cubicles of 7\' x 10\' to rooms of 10\' x 14\'. A room 8\' x 6\'

in width permits \"U\" shaped cabinetry around the chair.

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4630.1

APPENDIX 14

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Modern dentistry is performed with the patient in a supine

position and the dentist and chairside assistant in a seated

position. Many dentists who operate from a seated position

prefer the mobile dental unit to the older fixed floor-mounted

unit. Another type of dental unit is designed to be mounted

in the cabinetry behind the head of the patient. While not

having the flexibility of the mobile unit, the cabinet-mounted

unit can be located in a position that is more accessible to

both the dentist and his assistant than the fixed-floor mounted

unit. The method of operation and the selection of equipment

will strongly influence the design of the operatory.

With the exception of oral surgery, the operatories of all the

other dental specialities, such as pedodontics, periodontics,

orthodontics, etc., are basically the same.

g\. Oral Surgery Operatory. The oral surgery operatory can be

the same size as other operatories. Operatories designed

specifically for oral surgery often do not have dental

units as described in \"Operatories.\" A portable dental

engine is used instead. Scrub-up sinks and provisions for

sterilization and sterile supplies can be within the area,

but are usually in an alcove adjacent to the oral surgery

operatories. One or more small recovery rooms with accessible

toilet facilities should be provided in the oral surgery area.

1-4. SUPPORTING SERVICE AREAS

a\. Laboratory and X-ray Services.

\(1\) Some type of laboratory work will generally be done in

all but the very smallest group practice facilities.

In the very large facilities all, or almost all, of

the laboratory work will be done on the premises.

\(2\) In many facilities, space for routine fracture and

chest X-ray work must be provided. The X-ray facilities

may include both diagnostic X-ray and X-ray therapy.

Separate waiting areas nearby, particularly for X-ray

therapy, would be desirable. Besides the X-ray room,

the diagnostic X-ray and fluoroscopy space should include

a consultation-viewing room for the radiologist,

and a darkroom. Films should be filed in an adjoining

room or arranged so that the patient need not leave

the immediate area of the X-ray room. One X-ray room

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4630.1

APPENDIX 14

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(1-4) could be used for chest work, gastrointestinal work,

and routine radiography, depending on the caseload.

GI work is time-consuming; therefore, GI patients

need waiting space near the X-ray office. Therapeutic

X-ray providing facilities for superficial types of

treatment should include convenient dressing space, a

toilet room, and at least one recovery room. Care

must be taken in placing the X-ray equipment in the

room. In the case of diagnostic X-ray, the chest

cassette should be on an outside wall and, if possible,

the tube must be installed so that it does not point

in the direction of persons working in adjacent rooms.

Appropriate shielding must be provided according to

the National Bureau of Standards\' Handbooks No. 73

and 76 to reduce the effects of gamma and X-rays.

b\. Physical Therapy Service. Some clinics will include physical

therapy as a part of their total services. Such a service

generally includes some hydrotherapy-arm baths, leg baths,

and perhaps Hubbard tanks; and alcoves for massage,

electro-therapy, and diotherapy. A large room with various

types of exercise equipment may also be included in the clinic.

c\. Dental X-ray Service. X-ray cubicles or rooms should be a

minimum of 8 X 10 feet and should have radiation protection

equivalent to 1/16\" lead to height of 7\'0\". Controls are

usually outside the areas beneath a lead glass observation

window. A lavatory should be provided within the room. A

darkroom should be located as close as possible to the X-ray

cubicle or room. A combination transfer box and drier,

installed in the partition separating the darkroom from

another room or alcove in which the dental films could be

mounted and examined in white light, would facilitate

operations.

d\. Dental Laboratory. While many dental group practice clinics

will have the major portion of their prosthetic laboratory

work done by private dental laboratories, all clinics will

wish to have some laboratory facilities available. The full

range of work can be divided into five main categories: (1)

crown and bridge, (2) full dentures, (3) partial dentures,

\(4\) ceramics, and (5) orthodontics. Each category requires

specialized equipment which in turn determines the work area

and overall size of the laboratory.

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4/73 Page 6

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4630.1 CHG

APPENDIX 14

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e\. Pharmacy Service.

\(1\) Some group practice clinics may find it advantageous

to arrange for the inclusion of a pharmacy. The need

for one and its size depends upon the number and types

of medical disciplines it will serve.

\(2\) Even a minimum pharmacy will need storage space for a

large reserve stock of many items. Smaller quantities

will be kept in drug cabinets which should adjoin a

compounding and dispensing counter. Several hundred

chemicals and pharmaceuticals in various forms and

strengths must be stored in sectional cabinets, ready

for immediate use. A refrigerator with drawers will

be needed for keeping biologicals and thermolabile

preparations. Locked storage of narcotic preparations

must be provided.

1-5. AREAS FOR OTHER SPECIALISTS. Specialized examination and

treatment rooms may be required for special services. These are

usually provided on the basis of one room to each consultation

room.

a\. Otolaryngology Service (Ear, Nose, and Throat). The

examination and treatment room for the otolaryngologist should

be approximately the same size as a typical examination

room. In this room, instead of an examining table, an

adjustable examining and treatment chair with a cuspidor

connected to the water supply and drain should be provided.

\* b. Ophthalmology Service. The ophthalmologist will need a

consultation room and an examination room. The size and

number of the eye examination rooms depend on the patient

load. As a minimum, one examination room would be required

to house the refracting equipment and small desk. Additional

equipment the ophthalmologist uses for his examination could

be in this same room. In larger clinics it is frequently

desirable to have a separate room for eye refraction,

perimeter, and corrective treatment equipment. Patient load

may justify a separate room for measuring eye tension

although this procedure can be performed in the eye therapy

room. A small examination room with a treatment and

examining chair or table is all that is required for this

test. \*

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4630.1 CHG

APPENDIX 14

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\* c. Optometry Service. Except for surgery, the space needs of

the optometrist would be similar to those of the

ophthalmologist. If optician services are included, work space

and equipment may be provided here for filling prescriptions

for corrective lenses and for frames. A waiting room and space

for fitting frames may be needed.

d\. Psychiatry Service. This service may be found in large

group practice facilities. In some facilities, separate

exits may be desirable. The consultation room is the focal

point of the service. A larger room may be required for

conference or group therapy. A more extensive program may

include psychologists, social workers, or both, each of whom

would also need a typical consultation room.

e\. Podiatric Services. Podiatric examination and treatment

requires one or more appropriately equipped rooms. Such

rooms should be approximately 8\' X 10\' in size. Appropriate

radiological equipment should be located as close as possible

to the examination rooms. A hydraulic podiatry examination

and treatment unit will serve the best interests of the

podiatry department. The selection of the basic equipment

unit will, of course, influence the overall design and

furnishing of the room. A surgery clinic for minor podiatric

surgery may be included, and must comply with Paragraph 1-3(d)

of this appendix. In cases where podiatric services are a

part of a medical or osteopathic group practice, the Podiatry

Department should be located with easy access to the surgery

clinic. \*

1-6. SPECIAL SUBJECTS. A group facility shall comply with all

applicable laws, codes, ordinances and regulations which are

essential to assure a healthful, safe and sanitary facility.

a\. Sound Transmission. Airborne sound transmission shall be

minimized in consultation, examination, and waiting areas.

The limitation for airborne sound transmission class (STC)

for partitions and floors is 50 as determined by tests in

accordance with methods set forth in ASTM (American Society

for Testing Materials E90-61T.

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4630.1

APPENDIX 14

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(1-6) b. Storage. Adequate storage area for supplies shall be provided.

Provision should also be made for handling and storage

of soiled laundry and trash either through chutes or

appropriate collection arrangements.

c\. Work Areas (Nurses)

\(1\) Clean work area(s) shall be provided for the sterilization

of trays and instruments. Clean storage areas shall

be provided for sterile goods, including disposables.

\(2\) Soiled work area(s) shall be separated from clean work

areas. Space shall be provided for gross cleaning of

instruments prior to sterilization.

d\. Heating, Ventilating, and Air Conditioning.

\(1\) Air conditioning is recommended for geographic areas

where climatic conditions require it.

\(2\) Temperatures: (a) A minimum temperature of 75 degree F is

recommended for winter design conditions. (b) A maximum

temperature of 80 degree F is recommended for summer

design conditions. Systems should be designed to permit

the raising of temperatures at the discretion of the

physician in such areas as surgery, examination,

treatment and X-ray rooms where patient disrobing may be

necessary.

\(3\) Ventilation System Details. All air supply and air

exhaust systems shall be mechanically operated. All

fans serving exhaust systems should be located at the

discharge end of the system. The ventilation rates

shown on TABLE NO. A are recommended as minimum

acceptable rates and should not be construed as limiting

higher ventilation rates if they are required or appear

to be desirable to meet design conditions.

\(4\) Outdoor ventilation intakes, other than individual room

units, should be located as far away as practicable but

not less than 25 feet from the exhaust from any

ventilating system or combustion equipment.

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4630.1

APPENDIX 14

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(1-6) (5) All air systems should be designed to provide differential

air pressures between areas in a descending order

from clean areas to less clean areas. All air supplied

to sensitive areas such as surgery or examination and

treatment rooms should be delivered at or near the

ceiling of the room served, and all air exhausted from

the area served should be removed near floor level.

\(6\) The ventilation systems serving the surgery and

examination and treatment rooms where recirculation of air

is not permitted should be provided with filters rated

90 percent efficiency. Central systems serving

administration and other general areas should be provided

with filters rated at 80 percent efficiency. Filter

efficiencies should be based upon the National Bureau

of Standards Dust Spot Method on atmospheric dust.

\(7\) Ducts which penetrate construction intended for X-ray

or other ray protection should not impair the

effectiveness of the ray protection. Areas in which

anesthesia or oxygen is used and/or stored shall comply

with NFPA 56 \"Code for the Use of Flammable Anesthetics.\"

e\. Plumbing.

\(1\) Specific types of plumbing fixtures will be required

for the various clinical areas. These include handwashing

facilities and disposal sinks such as the clinical

sink and scrub sink. Wrist-action valves or knee or

foot-operated valves will facilitate the use of fixtures.

Among the clinical areas requiring handwashing or special

fixtures are examination and treatment, recovery,

isolation, and operating.

\(2\) All plumbing systems should be installed in accordance

with the requirements of USASI (United States of America

Standards Institute) A40.8 \"The National Plumbing Code.\"

f\. Electrical. Materials and installation shall comply with

the National Electrical Code. Independent feeders for X-ray

installations should be provided to reduce the problems of

voltage fluctuations. All equipment in installations should

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4630.1 CHG

APPENDIX 14

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conform to Article 660 of the National Electrical Code and

NEMA recommendations XR4-10. Fixed and mobile X-ray units

should be connected by means of independent feeders from

the main switchboard. Emergency power for lighting shall

be provided and emergency generating equipment shall be

provided for services deemed to be critical.

g\. Other Aspects of Mechanical and Electrical Equipment. Items

or elements of mechanical or electrical equipment in addition

to those already mentioned shall comply, as appropriate, with

Minimum Property Standards for Multifamily Housing.

h\. Fire Protection.

\(1\) Group practice facilities shall comply with the following

objectives:

To obtain a building which will provide a high degree

of safety of life and property preservation; to assure

planning and the use of materials which will retard

the spread of fire; and to provide means of egress

which will permit persons to leave the building with

safety, and not be harmed by fire, smoke, or heat.

\(2\) In order to meet the above objective, the provisions

of HUD\'s Minimum Property Standards for Multifamily

Housing, and those concerning Office Occupancy of

NFPA No. 101, \"Life Safety Code\", shall be used as

guidance for the appropriate specific subject.

i\. Materials, Products, Construction and Finishes. Building

materials, products, items, or elements of construction

and interior and exterior finishes shall comply, as

appropriate, with the HUD \"Minimum Property Standards for

Multifamily Housing.

1-7. EQUIPMENT. The classification of equipment items acceptable

for mortgage insurance purposes is made in this handbook.

Consultation with the HUD Field Office should be held by project

sponsors on questions concerning the inclusion of equipment.

Reference may be made to the American Hospital Association

Chart of Accounts for Hospitals, which lists many equipment

items and their estimated useful life.

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4630.1 CHG

APPENDIX 14

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TABLE NO. A

PRESSURE RELATIONSHIPS AND VENTILATION OF CERTAIN GROUP PRACTICE AREAS

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\* \*

\* \*

\* GRAPHICS MATERIAL IN ORIGINAL DOCUMENT OMITTED \*

\* \*

\* \*

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\*U.S. GOVERNMENT PRINTING OFFICE: 1976 - 210-966/248