types of hospital visits

Understanding the differences between inpatient vs outpatient care

Have you ever had surgery and spent the night in the hospital? Or maybe you’ve driven a loved one home from a same-day procedure, like a colonoscopy. It’s important to know how these services may appear on your health insurance bill — because one is called inpatient care and the other is called outpatient care.  

There can be quite a difference in what they cost and how your plan covers inpatient care vs outpatient care within the plan’s network of providers. The way to know the difference is whether you have to spend the night in a care setting (inpatient care) vs. being out the same day (outpatient care). Read on to learn about each type of care.

What is inpatient care?

Typically, inpatient care requires an overnight stay in a hospital or other care setting. Inpatient care tends to include more serious surgeries, procedures and care that require at least 1 overnight stay. Sometimes these visits are planned (like having a baby) and other times they’re not (like breaking a major bone). Inpatient care is needed for things like:

• Heart attack or stroke
• Orthopedic surgery
• Respiratory failure
• Bone fracture
• Certain mental health conditions
• Long-term care (like nursing homes)

What is outpatient care?

Outpatient care is anything that can be done in your doctor’s office or other medical clinic within a single day. Outpatient care and procedures include things like:

• Exams or consultations (like your yearly wellness exam)
• Same-day surgeries (like hernia repair, gallbladder removal or cataract surgery)
• Some emergency care (like stitches or care for a broken finger)
• Certain tests (like a mammogram or colonoscopy)
• Imaging (like X-rays, MRIs and CT scans)
• Lab work (like blood tests and tissue samples)

How are costs different for inpatient vs. outpatient medical care?

Like all health care services, there are many factors that determine how much care will cost — whether or not it’s inpatient or outpatient is one of them. You may have guessed inpatient care is usually more expensive because you’re staying overnight in a hospital. Inpatient care includes costs for days spent in the hospital, each provider who treats you and every procedure you have. The longer you stay in a medical facility, the bigger the bill (even if your health plan helps out).

Many health plans cover certain outpatient care. For example, preventive exams and some screenings are covered at 100%. Other outpatient care, like lab work, imaging and minor surgeries may also be covered — but at your plan’s benefit level. Outpatient costs will almost always be lower than inpatient costs.

Are there different doctors and providers for inpatient and outpatient care?

Most doctors can treat you in either an inpatient or outpatient setting. That said, specialists, like surgeons, may be more likely to provide inpatient care. For example, if you need back surgery, a specialist (orthopedic surgeon) will perform that type of procedure — likely in an inpatient setting. Common outpatient care, like labs, imaging and certain cancer screenings may be done by technicians.

What’s the difference between inpatient and outpatient mental health care?

When it comes to mental health , there are a variety of treatment options. Depending on the level of care someone needs, their provider will recommend inpatient and/or outpatient mental health care.

The main difference between the two is time spent in therapy and level of support during treatment. For example, inpatient mental health care allows for greater access to services in one facility (like access to nurses, mental health professionals or nutritionists). This type of temporary around-the-clock care is usually meant to treat someone’s mental health condition and help them get back to safely living on their own.

Outpatient mental health care is more flexible for those who need less support to manage their mental health. The time spent in outpatient therapy can vary depending on the individual and type of treatment they seek. For those who choose talk therapy, they may see a mental health professional a few hours each week.

When does someone need inpatient mental health care?

Inpatient mental health care is recommended in cases of mental health or medical crisis, or if there isn’t much support at home. A provider will refer patients to this type of care if certain requirements are met during assessment. Conditions that may require inpatient mental health care include:

• Eating disorders
• Psychotic disorders
• Alcohol use disorder
• Thoughts of suicide
• Medically assisted detox from drugs or alcohol

Inpatient mental health care can include hospitalization or admission to a mental health facility where there’s access to medical evaluations, therapies and/or constant care.

When does someone need outpatient mental health care?

Outpatient mental health care may be a good fit for someone with a safe home environment who doesn’t need medical detox or 24-hour supervision during their treatment. This type of mental health care is more common than inpatient care. It can be sought out on an as-needed basis, unless otherwise recommended by a provider. Conditions that may require inpatient mental health care include:

• Mood disorders

Outpatient mental health care may include different types of virtual or in-person therapy (like talk therapy) and/or medication . App-based mental health support is another option that has been gaining popularity.

Depending on your health plan, certain inpatient and outpatient mental health care may be covered. Always check your benefits to make sure you understand how your plan covers mental health services.

Choosing the right kind of care

It’s important to know which kind of care you need — and in which setting — so you can budget and minimize costs. Sometimes you may be able to choose whether you want inpatient or outpatient care, but other times you may not. If you find yourself planning for inpatient care, call your health plan to make sure you're choosing a network provider  and doing all you can to keep out-of-pocket costs down.

Your primary care provider will help you navigate your care options so you can make an informed decision.

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Inpatient vs. Outpatient: Comparing Two Types of Patient Care

More than ever, patients are engaged in their medical care, which is encouraging when you consider most medical school mission statements emphasize patient communication and education. It’s also worth noting that research shows providers are able to drive positive patient outcomes using a teach-back method that involves caring and clear language. Yet even well-informed individuals lack some knowledge, such as the distinction between inpatient versus outpatient care.

So what’s the difference, and why does it matter? This overview can help you advance your health literacy.

Inpatient vs. outpatient: Distinguishing the differences in care

What is an inpatient ? In the most basic sense, this term refers to someone admitted to the hospital to stay overnight, whether briefly or for an extended period of time. Physicians keep these patients at the hospital to monitor them more closely.

With this in mind, what is outpatient care? Also called  ambulatory care , this term defines any service or treatment that doesn’t require hospitalization. An annual exam with your primary care physician is an example of outpatient care, but so are emergent cases where the patient leaves the emergency department the same day they arrive. Any appointment at a clinic or specialty facility outside the hospital is considered outpatient care as well.

While there’s a clear difference between an inpatient and an outpatient, there is a little bit of gray area as well. Occasionally, physicians will assign a patient  observation status while they determine whether hospitalization is required. This period typically lasts for no more than 24 hours.

Also note that the location itself doesn’t define whether you’re an inpatient versus outpatient. It’s the duration of stay, not the type of establishment, that determines your status.

Inpatient vs. outpatient: Comparing services

You’re probably starting to get a sense of the varying circumstances that fit under each category. To further recognize the difference between inpatient and outpatient care, review the below treatments and services that are common for these two types of care.

Inpatient care examples

• Complex surgeries, as well as some routine ones
• Serious illnesses or medical issues that require substantial monitoring
• Childbirth, even in cases that don’t require a cesarean section
• Rehabilitation services for psychiatric illnesses, substance misuse, or severe injuries

Outpatient care examples

• X-rays, MRIs, CT scans, and other types of imaging
• Lab tests, such as bloodwork
• Minor surgeries, particularly ones that use less invasive techniques
• Colonoscopies
• Consultations or follow-ups with a specialist
• Routine physical exams
• Same-day emergent care, often treated at an urgent care facility versus the ER
• Chemotherapy or radiation treatment

Inpatient vs. outpatient: The providers in each setting

Primary care physicians  have traditionally been considered outpatient providers, while specialists are thought of as inpatient physicians. But that’s really an oversimplification, particularly when you consider that  hospitalists bridge the gap  by providing general medical care to inpatients. Effective care requires that doctors work together and effectively leverage health care technology , regardless of their specialties and settings.

Many physicians also divide their time between inpatient and outpatient services. OB/GYNs , for example, provide inpatient care when delivering babies and outpatient care when consulting with pregnant women during prenatal checkups.

Generally speaking, inpatients have contact with a larger group of providers. During a hospital stay, you could interact with physicians, nurse practitioners, lab technicians, physical therapists, pharmacists, and physician assistants.

Inpatient vs. outpatient: Cost considerations

The difference between inpatient versus outpatient care matters for patients because it will ultimately affect your eventual bill.

Outpatient care involves fees related to the doctor and any tests performed. Inpatient care also includes additional facility-based fees. The most recent cost data included in the Healthcare Cost and Utilization Project from the Agency for Healthcare Research and Quality (AHRQ) shows the average national inpatient charges can vary considerably depending on the length of stay and the treatment involved. The exact amount you pay also hinges on your insurance.

Things get a little more complicated  if you have Medicare . Outpatient care and physician-related services for inpatient care are covered by Part B. Hospital services like rooms, meals, and general nursing for inpatients are covered by Part A.

But if you stay overnight in the hospital under observation status, Medicare still considers you an outpatient and will not cover care in a skilled nursing facility. It can certainly be confusing, so don’t be afraid to ask the medical team about your status. They’re used to these types of questions.

Expand your medical knowledge

Hopefully, you now have a little more clarity concerning the definition of inpatient versus outpatient. It can go a long way towards helping you understand what you should expect during and after any sort of medical treatment.

You can further deepen your understanding of the health care world by reading our article “50 Must-Know Medical Terms, Abbreviations, and Acronyms .”

*This article was originally published in June 2019. It has since been updated to reflect information relevant to 2021.

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Types of Hospitals in the United States

There are more than 5000 hospitals in the United States. Patients should look for the right hospital for their needs.

Most hospitals provide medical and surgical care for acute (short-term) illnesses or conditions. The services available to patients can differ across hospital systems and even between hospitals within the same system. Hospitals’ approaches to patient care may differ based on hospital size, staffing, location, resources, and other factors. Because of these differences, it is important that patients and their caregivers understand which hospitals can offer the specific health care services that they need.

Community Hospitals (Nonfederal Acute Care)

Most US hospitals are classified as community hospitals according to the American Hospital Association. Two-thirds are located in large cities. Some community hospitals provide general care, and others focus on certain diseases and conditions, such as orthopedics, to provide specialty care. A general community hospital might also have areas of concentration or expertise, such as trauma and cancer care, that are often verified by accreditation organizations like the American College of Surgeons. Community hospitals can have as few as 6 beds or more than 500 beds.

Community hospitals can also be classified as major teaching, minor teaching, or nonteaching hospitals. Teaching hospitals train future physicians and other health care professionals. They also have ongoing research projects or clinical trials and provide care for patients with rare or complex conditions. Major teaching hospitals, or academic medical centers, may be affiliated with a medical school. Nonteaching hospitals have professionally trained medical staff and focus on providing essential care for patients in a community rather than medical training and research.

Federal Government Hospitals

About 200 hospitals are operated by the federal government in the United States. These hospitals provide care for routine medical and surgical problems for specific patient populations, such as active military personnel. The Department of Defense, the Department of Health and Human Services, and the Veterans Health Administration oversee these hospitals.

Nonfederal Psychiatric Care

More than 400 hospitals exist in the private sector to serve the unique needs of patients with mental health illnesses requiring acute hospital care. These hospitals treat conditions such as severe depression and substance abuse.

Nonfederal Long-term Care

Patients with extreme illness that no longer requires acute care are often referred to a long-term care hospital. These facilities provide medical and rehabilitative care for prolonged periods.

For More Information

Medicare Guide to Choosing a Hospital www.medicare.gov/pubs/pdf/10181-Guide-Choosing-Hospital.pdf

Medicare Checklist for Choosing a Hospital www.medicare.gov/files/hospital-checklist.pdf

American Hospital Association www.aha.org/research/rc/stat-studies/fast-facts.shtml

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Sources: American Hospital Association, Centers for Medicare & Medicaid Services

Howell MD. A 37-year-old man trying to choose a high-quality hospital: review of hospital quality indicators. JAMA . 2009;302(21):2353-2360.

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Liu JB , Kelz RR. Types of Hospitals in the United States. JAMA. 2018;320(10):1074. doi:10.1001/jama.2018.9471

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Differences Between Primary, Secondary, Tertiary, and Quaternary Care

Levels of Care

• Primary Care
• Secondary Care
• Tertiary Care

Quaternary Care

Frequently asked questions.

In medicine, there are four levels of care: primary, secondary, tertiary, and quaternary. The levels of care refer to the complexity of the medical cases that healthcare providers treat and the skills and specialties of the providers. 

• Primary care involves consulting with your primary care provider .
• Secondary care is when you see a specialist such as an oncologist (cancer expert) or endocrinologist (often for metabolic disorders like diabetes ).
• Tertiary care refers to specialized care in a hospital setting such as renal dialysis or heart surgery.
• Quaternary care is an advanced level of specialized care.

This article explains these terms. Knowing their definitions can help you better understand what your provider is talking about and help you recognize the level of care you're receiving.

Illustration by Michela Buttignol for Verywell Health

Primary Care: Essentials

Most people are very familiar with primary care. This office is your first stop for most of your symptoms and medical concerns. You might seek primary care for the following:

• Illness : You may see your primary care provider when you notice a new symptom or when you come down with a cold, the flu, or some other infection.
• Injury : You may also seek primary care for a broken bone, a sore muscle, a skin rash, or any other acute medical problem .
• Chronic health conditions: You may work with a primary care provider to manage chronic conditions such as high blood pressure, diabetes, heart disease, obesity, anxiety, and depression.
• Referral : Primary care is typically responsible for coordinating your care among specialists and other levels of care.

In addition, you'll probably see a primary care provider (PCP) for regular health screenings , general checkups, and wellness visits.

Primary care providers may be:

• Nurse practitioners
• Physician assistants

There are some primary care specialties as well. For instance, obstetrics and gynecology ( OB-GYN ) specialists, geriatricians who treat older people, and pediatricians are all primary care providers. But they also happen to specialize in caring for a particular group of people.

Studies have shown that primary care providers benefit the healthcare system by:

• Enhancing access to healthcare services
• Providing better health outcomes
• Decreasing hospitalization and use of emergency department visits

Most health insurance policies require you to designate a primary care provider. In most cases, you can choose a family practice physician, internist, OB-GYN, geriatrician, or pediatrician.

Secondary Care: Specialists

Secondary care occurs when your primary care provider refers you to a specialist. Secondary care means your healthcare provider has transferred your care to someone who has more specific expertise in whatever health issue you are experiencing. They remain in contact with the specialist.

Specialists focus either on a specific system of the body or a particular disease or condition. Examples of specialists include:

• Cardiologists , who focus on the heart and blood vessels
• Endocrinologists, who focus on hormone systems, including diseases like diabetes and thyroid disease
• Oncologists, who specialize in treating cancers, and many focus on a specific type of cancer

Your insurance company may require that you receive a referral from your PCP rather than going directly to a specialist.

Sometimes problems arise in secondary care. These may include:

• Wrong specialist : Sometimes, doctors refer people to the wrong kind of specialist. That can happen because symptoms often overlap between a variety of health conditions. So, your symptoms may suggest one problem when, in reality, it is another condition that requires a different specialist.
• Lack of coordination of care : You may also experience problems if you're seeing more than one specialist and each is treating a different condition. Sometimes in these cases, doctors might not fully coordinate your care. Ideally, specialists should work with your primary care health team to ensure everyone knows what the others are recommending.

Tertiary Care and Hospitalization

If you are hospitalized and require a higher level of specialty care, your doctor may refer you to a tertiary care center. Tertiary care refers to highly specialized equipment and expertise to treat specific, complex health conditions.

Examples of medicine and procedures performed at tertiary care centers include:

• Plastic surgery
• Neurosurgery
• Organ transplants
• Head and neck oncology
• Perinatology (high-risk pregnancies)
• Neonatology ICU (high-risk newborn care)
• Trauma surgery
• High-dose chemotherapy for cancer
• Coronary artery bypass graft ( CABG )
• Burn treatment

A small, local hospital may not be able to provide advanced care, so you may be transferred to a tertiary care center.

Studies have shown that when you are in tertiary care for certain chronic conditions such as diabetes and chronic kidney disease, your PCP must remain involved. That's because your PCP can help you establish and maintain a management plan for the long term.

Quaternary care is considered an extension of tertiary care. However, it is even more specialized and highly unusual.

Because it is so specific, not every hospital or medical center offers quaternary care. Some may only provide quaternary care for particular medical conditions or systems of the body.

The types of quaternary care include:

• Experimental medicine and procedures
• Uncommon and specialized surgeries

Levels of care refer to the complexity of medical cases, the types of conditions a physician treats, and their specialties.

Primary care involves your primary healthcare provider. You see them for things like acute illnesses, injuries, screenings, or to coordinate care among specialists.

Secondary care is the care of a specialist. These specialists may include oncologists, cardiologists, and endocrinologists.

Tertiary care is a higher level of specialized care within a hospital. Similarly, quaternary care is an extension of tertiary care, but it is more specialized and unusual.

It depends on the hospital and the services you receive. A secondary care hospital is typically a smaller facility that lacks specialized equipment. If you are at a secondary-care level hospital and need more specialized care, you will be transferred to a tertiary-care hospital. Examples of tertiary care include coronary artery bypass surgery, severe burn treatments, neurosurgery, and dialysis. 

No, tertiary care and Level III care are different. Care levels discussed in Roman numerals refer to trauma center designations. Care levels discussed in ordinals (primary, secondary, etc.) describe the intensity of care and are commonly used for insurance purposes.

Care levels are named in ascending order lowest level of care (primary) to highest intensity (quaternary). Trauma care levels descend from the lowest level (Level V trauma center) to the highest level of care (Level I trauma center).

Mallender, J. What are Levels of Care? A Simple Guide.

Harvard Medical School. Why do you need a primary care physician?

Vimalananda VG, Meterko M, Waring ME, Qian S, Solch A, Wormwood JB, et al. Tools to improve referrals from primary care to specialty care . Am J Manag Care . 2019 Aug 1;25(8):e237-e242. PMID: 31419100.

Beheshti L, Kalankesh LR, Doshmangir L, Farahbakhsh M. Telehealth in Primary Health Care: A Scoping Review of the Literature . Perspect Health Inf Manag . 2022 Jan 1;19(1):1n. PMID: 35440933

Scaioli G, Schäfer WLA, Boerma WGW, Spreeuwenberg P, van den Berg M, Schellevis FG, et al . Patients' perception of communication at the interface between primary and secondary care: a cross-sectional survey in 34 countries . BMC Health Serv Res . 2019 Dec 30;19(1):1018. doi: 10.1186/s12913-019-4848-9.

National Health Service. The healthcare ecosystem .

Lo C, Ilic D, Teede H, et al. Primary and tertiary health professionals' views on the health-care of patients with co-morbid diabetes and chronic kidney disease - a qualitative study .  BMC Nephrol . 2016;17(1):50. doi:10.1186/s12882-016-0262-2

Joshi S, Smith Z, Soman S, Jain S, Yako A, Hojeij M, et al . Low- Versus High-Dose Methylprednisolone in Adult Patients With Coronavirus Disease 2019: Less Is More . Open Forum Infect Dis. 2021 Dec 8;9(1):ofab619. doi: 10.1093/ofid/ofab619. 

By Trisha Torrey  Trisha Torrey is a patient empowerment and advocacy consultant. She has written several books about patient advocacy and how to best navigate the healthcare system. 

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Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-.

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet].

Statistical brief #174 overview of emergency department visits in the united states, 2011.

Audrey J Weiss , PhD, Lauren M Wier , MPH, Carol Stocks , PhD, RN, and Janice Blanchard , MD, PhD.

Published: June 2014 .

• Introduction

Emergency departments (EDs) provide a significant source of medical care in the United States, with over 131 million total ED visits occurring in 2011. 1 Over the past decade, the increase in ED utilization has outpaced growth of the general population, despite a national decline in the total number of ED facilities. 2 , 3 In 2009, approximately half of all hospital inpatient admissions originated in the ED. 4 In particular, EDs were the primary portal of entry for hospital admission for uninsured and publicly insured patients (privately insured patients were more likely to be directly admitted to the hospital from a doctor's office or clinic). 5

ED utilization reflects the greater health needs of the surrounding community and may provide the only readily available care for individuals who cannot obtain care elsewhere. 6 Many ED visits are “resource sensitive” and potentially preventable, meaning that access to high-quality, community-based health care can prevent the need for a portion of ED visits.

This HCUP Statistical Brief presents data on ED visits in the United States in 2011. Patient and hospital characteristics for two types of ED visits are provided: ED visits with admission to the same hospital and ED visits resulting in discharge, which includes patients who were stabilized in the ED and then discharged home, transferred to another hospital, or any other disposition. The most frequent conditions treated by patient age group also are presented for both types of ED visits. All differences between estimates noted in the text are statistically significant at the .0005 level or better.

• In 2011, there were about 421 visits to the emergency department (ED) for every 1,000 individuals in the population.
• More than five times as many individuals who visited an ED were discharged as were admitted to the same hospital.
• Among patients younger than 18 years, the most common reasons for admission to the hospital after an ED visit were acute bronchitis (infants younger than 1 year), asthma (patients aged 1–17 years), and pneumonia (infants and patients aged 1–17 years).
• For adults aged 45–84 years, septicemia (infection in the bloodstream) was the most frequent reason for admission to the hospital after an ED visit.
• Medicare was the primary payer for more than half of ED visits that resulted in admission to the same hospital.
• The most common reasons for ED visits resulting in discharge were fever and otitis media (infants and patients aged 1–17 years), superficial injury (all age groups except infants), open wounds of the head, neck, and trunk (patients aged 1–17 years and adults aged 85+ years), nonspecific chest pain (adults aged 45 years and older), and abdominal pain and back pain (all adult age groups except those aged 85+ years).
• Rural areas had a higher rate of ED visits resulting in discharge compared with urban areas.

Emergency department visits by selected patient and hospital characteristics, 2011

In 2011, rates of ED visits varied by the patient's sex, age group, residence, and hospital region ( Figure 1 ).

Rate of emergency department visits by the patient's sex, age group, residence, and hospital region, 2011. Note: “ED visits resulting in discharge” includes patients who were stabilized in the ED and then discharged home, transferred to (more...)

• In 2011, more than five times as many individuals who visited the ED were discharged as were admitted to the same hospital. Overall, in 2011 there were 421 ED visits per 1,000 population. More than five times as many individuals who visited the ED were discharged (359 per 1,000 population) as were admitted to the same hospital (62 per 1,000 population).
• Overall, females had about a 20 percent higher rate of ED visits than males. Females had a higher overall rate of ED visits than males (458 versus 382 per 1,000 population). The rate of ED visits that resulted in discharge was over 20 percent higher for females than males (392 versus 324 per 1,000 population).
• Infants younger than 1 year and adults aged 85 years and older had the highest rate of ED visits, but the older adults were far more likely to be admitted to the same hospital. Infants and adults aged 85 years and older had the highest rate of ED visits overall (816 and 935 per 1,000 population, respectively) and the highest rate of ED visits that resulted in discharge (756 and 508 per 1,000 population, respectively). Adults aged 65–84 years and adults aged 85 years and older had the highest rates of ED visits with admission to the same hospital (180 and 427 per 1,000 population, respectively). Among infants younger than 1 year and patients aged 1–17 years and 18–44 years, fewer than 10 percent of all ED visits resulted in admission to the same hospital (7.4 percent, 3.3 percent, and 7.3 percent, respectively). The proportion of ED visits with admission to the same hospital increased as age increased among the following groups: 45–64 years (19.3 percent), 65–84 years (36.4 percent), and 85 years and older (45.7 percent).
• Rural areas had the highest rate of ED visits resulting in discharge. Rural areas (micropolitan and noncore areas) had the highest rate of ED visits that resulted in discharge in 2011 (448 per 1,000 population) compared with urban areas: medium and small metropolitan areas (375), large metropolitan counties (319), and large metropolitan cities (324). ED visits with admission to the same hospital did not differ substantially by patient residence.
• Western States had the lowest rate of ED visits. Western States had the lowest rate of ED visits overall (321 per 1,000 population) compared with the other three U.S. regions: South (444), Midwest (460), and Northeast (453). The lower ED visit rate in the West occurred for ED visits with admission to the same hospital (48 per 1,000 population) and ED visits resulting in discharge (273 per 1,000 population).

The proportions of ED visits that were attributable to each expected primary payer are provided in Figure 2 .

Proportions of emergency department visits by expected primary payer, 2011. Note: “ED visits resulting in discharge” includes patients who were stabilized in the ED and then discharged home, transferred to another hospital, or any other (more...)

• Among all ED visits in 2011, private insurance and Medicaid were the most common expected primary payers. Of the 131 million total ED visits in 2011, 29 percent were billed to private insurance, 27 percent to Medicaid, and 22 percent to Medicare. For 16 percent of all ED visits, there was no insurance coverage.
• For ED visits with admission to the same hospital, Medicare was the most common primary payer. Medicare was billed for 52 percent of the 19.3 million ED visits that resulted in admission to the same hospital in 2011. Private insurance was the second most common primary expected payer, billing for 23 percent of all ED visits that resulted in hospital admission, followed by Medicaid, which was billed for 16 percent of these ED visits. Approximately 7 percent of ED visits with admission to the same hospital were not covered by any insurance.
• For ED visits resulting in discharge, nearly one-fifth were uninsured. Fully 18 percent of the 111.7 million ED visits that resulted in discharge had no insurance coverage. Private insurance and Medicaid were the most common primary payers for these ED visits (31 percent and 29 percent, respectively).

Reasons for emergency department visits by patient age group, 2011

Tables 1 and 2 provide the most common principal conditions identified in 2011 for admission to the same hospital after an ED visit ( Table 1 ) and ED visits resulting in discharge ( Table 2 ) by patient age group.

Top five principal conditions for admission to the same hospital after an emergency department visit, by age group, 2011.

Top five principal conditions for emergency department visits resulting in discharge, by age group, 2011.

• The five most common reasons for admission to the same hospital after an ED visit constituted between 18.2 percent and 40.8 percent of the ED visits, depending on the patient's age group. In 2011, the five most common principal conditions accounted for 40.8 percent of all infant admissions to the same hospital after an ED visit. The five top-ranked reasons constituted about one-third of the admissions after an ED visit among patients aged 1–17 years (34.5 percent) and adults aged 85 years and older (30.1 percent). The most frequent principal conditions accounted for one-fourth or less of the admissions after an ED visit among adults aged 18–44 years (19.6 percent), 45–64 years (18.2 percent), and 65–84 years (25.8 percent).
• Pneumonia and other respiratory conditions were top-ranked reasons for admission to the same hospital after an ED visit for all age groups except those aged 18–44 years. In 2011, pneumonia was either the second or third most common reason for admission to the same hospital after an ED visit for all age groups except adults aged 18–44 years (pneumonia was the ninth most common condition in this age group, data not shown). Other respiratory conditions also were common for most age groups. Acute bronchitis was the most common reason for admission to the same hospital after an ED visit for infants, and asthma was the most common diagnosis for patients aged 1–17 years. Chronic obstructive pulmonary disease and bronchiectasis was the fourth most common reason for admission to the same hospital after an ED visit for adults aged 45–64 years and 65–84 years.
• Septicemia and cardiac conditions were top reasons for admission to the same hospital after an ED visit among adults aged 45 years and older. Septicemia was the most common reason for admission to the same hospital after an ED visit among adults aged 45–64 years and 65–84 years. Septicemia also was the second most common diagnosis among adults aged 85 years and older. Congestive heart failure was the top-ranked reason for admission to the same hospital after an ED visit among adults aged 85 years and older and the second most common reason among adults aged 65–84 years. Other cardiac conditions also were common: nonspecific chest pain was the second most common reason for admission to the same hospital after an ED visit among adults aged 45–64 years, and cardiac dysrhythmias were the fifth most common reason among those aged 65–84 years.
• Mood disorders were a common type of diagnosis among younger patients admitted to the same hospital after an ED visit. A mood disorders diagnosis was the most common reason for admission to the same hospital after an ED visit among adults aged 18–44 years. Schizophrenia and other psychotic disorders also were common among this age group, ranking fourth among reasons for admission to the same hospital. Mood disorders were the fourth most common type of diagnosis among patients aged 1–17 years.
• The five most common reasons for ED visits resulting in discharge constituted between 21.1 percent and 32.6 percent of the ED visits, depending on the patient's age group. In 2011, the five top-ranked principal conditions accounted for 32.6 percent of all ED visits for infants that resulted in discharge. The five most common reasons constituted about one-fourth of ED visits among patients aged 1–17 years (25.8 percent), adults aged 18–44 years (24.9 percent), and adults aged 45–64 years (26.5 percent). The most frequent principal conditions accounted for about one-fifth of ED visits that resulted in discharge among adults aged 65–84 years (21.1 percent) and adults aged 85 years and older (21.8 percent).
• Fever and otitis media were common principal conditions diagnosed during ED visits resulting in discharge among patients younger than 18 years. Fever of unknown origin was the most common diagnosis for ED visits that resulted in discharge among infants younger than 1 year. Fever also was the fifth most common condition among patients aged 1–17 years. Otitis media and related conditions (ear infections) was the second most frequent reason for ED visits resulting in discharge among infants and patients aged 1–17 years.
• Injuries—including contusions, open wounds, and sprains—were common reasons for ED visits resulting in discharge among all age groups except infants. Superficial injury was the most common reason for ED visits resulting in discharge among patients aged 1–17 years and adults aged 85 years and older. Superficial injury also was among the top five reasons for ED visits resulting in discharge among other adult age groups, ranking second among adults aged 65–84 years, third among adults aged 18–44 years, and fifth among adults aged 45–64 years. Other injury-related conditions also were commonly observed during ED visits resulting in discharge. Open wounds of the head, neck, and trunk were frequent reasons for ED visits that resulted in discharge among patients aged 1–17 years and adults aged 85 years and older. Sprains and strains were common among patients aged 1–17 years, adults aged 18–44 years (where it was the top-ranked condition), and adults aged 45–64 years. Open wounds of extremities were the fifth most common type of diagnosis among adults aged 85 years and older.
• Nonspecific chest pain was a top-ranked principal condition for ED visits resulting in discharge among adults aged 45 years and older. Nonspecific chest pain was the most common reason for ED visits that resulted in discharge for adults aged 45–64 years and 65–84 years. Nonspecific chest pain was the third most common diagnosis among adults aged 85 years and older.
• Abdominal pain and back problems were among the five most frequent reasons for ED visits resulting in discharge among all adult age groups except those aged 85 years and older. Abdominal pain was one of the most common reasons for adult ED visits that resulted in discharge, ranking as the second most common reason among adults aged 18–44 years, ranking fourth among adults aged 45–64 years, and ranking third among adults aged 65–84 years. Spondylosis, intervertebral disc disorders, and other back problems also were a common type of diagnosis for adult ED visits resulting in discharge, ranking fourth among adults aged 18–44 years and 65–84 years and ranking third among adults aged 45–64 years.
• Data Source

The estimates in this Statistical Brief are based upon data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS), 2011. The statistics were generated from HCUPnet, a free, online query system that provides users with immediate access to the largest set of publicly available, all-payer national, regional, and State-level hospital care databases from HCUP. 7

Many statistical tests were conducted for this Statistical Brief. Thus, to decrease the number of false-positive results, we reduced the significance level to .0005 for individual tests.

• Definitions

Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or develop during the stay.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are approximately 14,000 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnoses into a manageable number of clinically meaningful categories. 8 This “clinical grouper” makes it easier to quickly understand patterns of diagnoses. CCS categories identified as “Other” typically are not reported; these categories include miscellaneous, otherwise unclassifiable diagnoses that may be difficult to interpret as a group.

Types of hospitals included in HCUP

HCUP is based on data from community hospitals, which are defined as short-term, non-Federal, general, and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include obstetrics and gynecology, otolaryngology, orthopedic, cancer, pediatric, public, and academic medical hospitals. Excluded are long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Community hospitals included in the Nationwide Emergency Department Sample (NEDS) have hospital-based emergency departments and no more than 90 percent of their ED visits resulting in admission.

Unit of analysis

The unit of analysis is the emergency department (ED) encounter, not a person or patient. This means that a person who is seen in the ED multiple times in one year will be counted each time as a separate “encounter” in the ED.

Location of patients' residence

Place of residence is based on the urban-rural classification scheme for U.S. counties developed by the National Center for Health Statistics (NCHS). For this Statistical Brief, we collapsed the NCHS categories into either urban or rural according to the following:

• Large Central Metropolitan: includes metropolitan areas with 1 million or more residents Large Fringe Metropolitan: includes counties of metropolitan areas with 1 million or more residents Medium and Small Metropolitan: includes areas with 50,000 to 999,999 residents.
• Micropolitan and Noncore: includes nonmetropolitan counties (i.e., counties with no town greater than 50,000 residents).

Payer is the expected primary payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into general groups:

• Medicare: includes patients covered by fee-for-service and managed care Medicare
• Medicaid: includes patients covered by fee-for-service and managed care Medicaid
• Private Insurance: includes Blue Cross, commercial carriers, and private health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
• Uninsured: includes an insurance status of “self-pay” and “no charge”
• Other: includes Worker's Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.

Hospital stays billed to the State Children's Health Insurance Program (SCHIP) may be classified as Medicaid, Private Insurance, or Other, depending on the structure of the State program. Because most State data do not identify SCHIP patients specifically, it is not possible to present this information separately.

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

Region is one of the four regions defined by the U.S. Census Bureau:

• Northeast: Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, and Pennsylvania
• Midwest: Ohio, Indiana, Illinois, Michigan, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas
• South: Delaware, Maryland, District of Columbia, Virginia, West Virginia, North Carolina, South Carolina, Georgia, Florida, Kentucky, Tennessee, Alabama, Mississippi, Arkansas, Louisiana, Oklahoma, and Texas
• West: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, Nevada, Washington, Oregon, California, Alaska, and Hawaii
• For More Information

For more information about HCUP, visit http://www.hcup-us.ahrq.gov/ .

For additional HCUP statistics, visit HCUPnet, our interactive query system, at http://hcupnet.ahrq.gov/ .

For information on other hospitalizations in the United States, refer to the following HCUP Statistical Briefs located at http://www.hcup-us.ahrq.gov/reports/statbriefs/statbriefs.jsp:

• Statistical Brief #166, Overview of Hospital Stays in the United States, 2011
• Statistical Brief #168, Costs for Hospital Stays in the United States, 2011
• Statistical Brief #162, Most Frequent Conditions in U.S. Hospitals, 2011
• Statistical Brief #165, Most Frequent Procedures Performed in U.S. Hospitals, 2011

For a detailed description of HCUP, more information on the design of the Nationwide Emergency Department Sample (NEDS), and methods to calculate estimates, please refer to the following publications:

Introduction to the HCUP Nationwide Emergency Department Sample, 2010. Online. November 2012. U.S. Agency for Healthcare Research and Quality. http://hcup-us.ahrq.gov/db/nation/neds/NEDS2010Introductionv3.pdf . Accessed May 7, 2014.

Introduction to the HCUP State Emergency Department Databases. Online. August 2013. U.S. Agency for Healthcare Research and Quality. http://hcup-us.ahrq.gov/db/state/sedddist/Introduction_to_SEDD.pdf . Accessed May 7, 2014.

HCUPnet. 2011 National Statistics, All ED Visits. [May 7, 2014]. http://hcupnet ​.ahrq.gov/HCUPnet.jsp ..

Tang N, Stein J, Hsia RY, Maselli JH, Gonzales R. Trends and characteristics of US emergency department visits, 1997–2007. Journal of the American Medical Association. 2010; 304 (6):664–70. [ PMC free article : PMC3123697 ] [ PubMed : 20699458 ].

Goodell S, DeLia D, Cantor JC. Robert Wood Johnson Foundation Policy Brief No. 17. Princeton, NJ: Robert Wood Johnson Foundation; 2009. [May 7, 2014]. Emergency Department Utilization and Capacity. http://www ​.rwjf.org/content ​/dam/farm/reports ​/issue_briefs/2009/rwjf43566 .

Morganti-Gonzalez K, Baufman S, Blanchard J, Abir M, Iyer N, Smith A, et al. The Evolving Role of Emergency Departments in the United States. RAND RR 280-ACEP. Santa Monica, CA: Rand Corp; May, 2013. [ PMC free article : PMC4945168 ] [ PubMed : 28083290 ].

Ibid. Note: excludes live births.

Tang et al., 2010.

Agency for Healthcare Research and Quality. HCUPnet web site. [May 7, 2014]. http://hcupnet ​.ahrq.gov/ .

HCUP Clinical Classifications Software (CCS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: U.S. Agency for Healthcare Research and Quality; [May 7, 2014]. Updated April 2014. http://www ​.hcup-us.ahrq ​.gov/toolssoftware/ccs/ccs.jsp ..

About Statistical Briefs HCUP Statistical Briefs are descriptive summary reports presenting statistics on hospital inpatient and emergency department use and costs, quality of care, access to care, medical conditions, procedures, patient populations, and other topics. The reports use HCUP administrative health care data.

About the NEDS The HCUP Nationwide Emergency Department Database (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., treat-and-release visits and transfers to another hospital); the SID contain information on patients initially seen in the emergency room and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decisionmaking regarding this critical source of care. The NEDS is produced annually beginning in 2006.

About HCUPnet HCUPnet is an online query system that offers instant access to the largest set of all-payer health care databases that are publicly available. HCUPnet has an easy step-by-step query system that creates tables and graphs of national and regional statistics as well as data trends for community hospitals in the United States. HCUPnet generates statistics using data from HCUP's Nationwide Inpatient Sample (NIS), the Kids' Inpatient Database (KID), the Nationwide Emergency Department Sample (NEDS), the State Inpatient Databases (SID), and the State Emergency Department Databases (SEDD).

Suggested Citation Weiss AJ (Truven Health Analytics), Wier LM (Truven Health Analytics), Stocks C (AHRQ), Blanchard J (RAND). Overview of Emergency Department Visits in the United States, 2011. HCUP Statistical Brief #174. June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www ​.hcup-us.ahrq ​.gov/reports/statbriefs ​/sb174-Emergency-Department-Visits-Overview.pdf .

• Cite this Page Weiss AJ, Wier LM, Stocks C, et al. Overview of Emergency Department Visits in the United States, 2011. 2014 Jun. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006 Feb-. Statistical Brief #174.
• PDF version of this page (167K)

In this Page

• Healthcare Cost and Utilization Project (HCUP)
• Nationwide Inpatient Sample (NIS)
• Kids' Inpatient Database (KID)
• Nationwide Emergency Department Sample (NEDS)
• State Inpatient Databases (SID)
• State Ambulatory Surgery Databases (SASD)
• State Emergency Department Databases (SEDD)
• HCUP Overview
• HCUP Fact Sheet
• HCUP Partners
• HCUP User Support

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Home Healthcare

Different types of hospitalization and hospital admissions.

SonderCare Learning Center

What are Different Types of Hospitalization and Hospital Admissions? People are sent to the hospital for many reasons, not just for serious operations or treating life-threatening emergencies. There are several types of hospitalization and hospital admission for inpatient management. The most common are Elective Admissions, Direct Admissions, Holding Admissions, and Emergency Admissions. Depending on the needs, these admissions bring different levels of medical care.

Learn About Different Healthcare Admissions and Hospitalizations

Elective hospital admissions.

Elective hospital admissions make up most admissions, though how many depends on the hospital. These stays are when someone has a known medical condition or complaint that requires further treatment or surgery and hospital care, but patients can work with their doctor to alter the time of the admission for convenience. A doctor will make a hospital bed reservation for the patient on a specific day that can change as needed.

The doctor may tell the patient to go to the hospital in advance for lab tests, X-rays, ECGs, or other prescreening tests. For seniors aging at home or in a facility, as well as patients with mobility needs, an in-home hospital bed for resting before or after the elective date can make the experience much more comfortable.

Direct Admission Hospitalization

Direct admission would occur after the patient has seen or spoken to their doctor, who feels they must admit them to the hospital for immediate medical care. The doctor may arrange an ambulance to take the patient to the hospital or request that they go to the hospital themselves; the doctor may be able to make a bed reservation, too.

Holding Admission Hospital Stays

Holding or observation admission often takes place through the emergency department. The patient is admitted for diagnostic testing and, unless something shows up that requires another level of care, they will be discharged within 24 to 48 hours.

For example, if a senior loved one has chest pain that does not appear to be related to cardiovascular disease, but it’s not 100% in the doctor’s expert opinion, the patient may be admitted for further tests to ensure it wasn’t a cardiac episode. If the holding shows that they had a heart attack, the healthcare providers make it a full admission; if not, they would be discharged and sent to the doctor for further testing.

Emergency Admission Hospitalization

Finally, there are emergency admissions, which go through the hospital’s emergency department. A medical emergency is any serious injury, condition, or symptom posing an immediate risk to someone’s life or health. If they need emergency care, the hospital may admit the patient to a floor, a specialized unit, or an observation unit.

How Can I Prepare For Hospital Admission?

Seniors and their loved ones won’t always know when a hospital visit is necessary. What they can do is be prepared when it has to happen. Everyone should have the following information stored in a safe, central location in case of hospital admission.

• Identification like a driver’s license, medical card, emergency contacts (relatives and friends names and phone numbers), and name(s) of the primary care physician and the specialists that treat the patient.
• A list of all current medications – including strength and frequency – as well as any treatments or over-the-counter medications. Never lie about what you are taking.
• Necessary medications. Keep them in a carrying case or have one handy for quick packing.
• A list of all allergies, including the reaction the patient has to them.
• A list of all medical conditions and all past surgeries or procedures (not just the most recent).
• Make sure to fill out a living will and appoint a medical power of attorney. This way, your wishes about end-of-life medical treatment are documented if you cannot speak for yourself.

If you or a loved one are in the hospital for an elective admission, you have more time to prepare. Another loved one can also supply them should an emergency or holding admission be necessary. 

• Important personal items like smartphones, chargers, batteries, eyeglasses, mobility equipment, and hearing aids.
• Toiletries, like soap, shampoo, a toothbrush, toothpaste, deodorant, and a hairbrush. The hospital will likely have basic supplies, but many patients do not like them.
• Moisturizer and lip balm. Hospitals can be very drying, making the patients uncomfortable.
• Clean underwear, socks, and pajamas.

Being admitted to the hospital for care and recovery can be stressful; the problem can be more difficult if a patient has Alzheimer’s disease or dementia. An in-home hospital bed and other assistive equipment may help patients reduce the amount of time they need to spend in a medical facility and help them get back to familiar surroundings sooner.

Frequently Asked Questions About Types Of Hospitalization

Entrance into the hospital on an elective basis to treat or diagnose a specific medical condition. The emergency department also admits patients on an emergency basis. Same-day surgery is another common admission type.

The first step in admission is securing a physician admitting orders sheet/doctor’s order or admission notice slip from the emergency department. As a second step, secure permission for admission and gather data before verifying completed forms for completeness and accuracy. As a final step, confirm room preferences and coordinate with nursing staff.

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Inpatient hospital care

Medicare Part A (Hospital Insurance) covers inpatient hospital care if you meet both of these conditions:

• You’re admitted to the hospital as an inpatient after an official doctor’s order, which says you need inpatient hospital care to treat your illness or injury
• The hospital accepts Medicare

Your costs in Original Medicare

You pay this in each benefit period :

• Days 1–60 : $1,632 deductible.
• Days 61–90 : $408 each day.
• Days 91 and beyond : $816 each day while using your 60 lifetime reserve days.
• Each day after you use all of your lifetime reserve days: All costs.

Frequency of services

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and if, or how much, Medicare will pay for them.

Medicare-covered inpatient hospital services include:

• Semi-private rooms
• General nursing
• Drugs (including methadone to treat an opioid use disorder)
• Other hospital services and supplies as part of your inpatient treatment

Medicare doesn't cover:

• Private-duty nursing
• A private room (unless medically necessary)
• A television or phone in your room (if there's a separate charge for these items)
• Personal care items (like razors or slipper socks)

Things to know

Part A only pays for up to 190 days of inpatient mental health care in a freestanding psychiatric hospital during your lifetime. The 190-day limit doesn’t apply to care you get in a Medicare-certified, distinct part psychiatric unit within an acute care or critical access hospital.

Inpatient hospital care includes care you get in:

• Acute care hospitals
• Critical access hospitals
• Inpatient rehabilitation facilities
• Inpatient psychiatric facilities
• Long-term care hospitals

It also includes inpatient care you get as part of a qualifying clinical research study.

If you also have Part B, it generally covers 80% of the Medicare-approved amount for doctor’s services you get while you’re in a hospital.

Related resources

• Find hospitals
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• Steps to Choosing a Hospital Checklist
• Find out if you're an inpatient or an outpatient—it affects what you pay
• Skilled nursing facility coverage
• Long-term care hospital coverage
• Surgery (estimating costs)
• Your rights in the hospital
• Hospital Discharge Planning Checklist [PDF, 330KB]
• Medicare & You: Planning for Discharge from a Health Care Setting (video)
• See how Medicare is responding to COVID-19

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Types of Appointments

Office visit, wellness physical, pre-travel consultation, blood draw/vaccinations.

Office visits, otherwise known as focused visits, are best suited for 1-3 topics you want to discuss. Depending on the complexity of the concerns, all three topics can be taken care in one visit. However, sometimes to ensure the highest quality of care we request you come back for a follow-up visit to ensure there is enough time to address your needs.

This is the most common appointment type and is divided into levels 1 through 5 (each with its own Current Procedural Terminology (CPT) code) based on counseling time, medical risk, and decision-making criteria that are very complex. Most clinics use professional coders and/or software to help generate CPT codes for an office visit, which defends the clinic against any claim that it applies charges to different types of patients differently. Believe it or not, “down-coding” an appointment in order to charge a patient less than the calculated office visit level is penalized the same as “up-coding” in order to charge a patient more than the calculated office visit level! The legal word that describes this is “malfeasance” by unfairly favoring some patients over others. Most office visits trigger the CPT code for one of levels 3 through 5, since level 1 can’t even involve the doc and level 2 gets surpassed readily in visits of any substance.

During this visit type, we review your past medical history, family medical history, health habits, current medications, and allergies. We perform a screening physical exam. We synthesize the information into a personalized assessment of disease risk. We recommend for or against additional screening tests to screen for common cancers, and screening tests to help clarify your risk status for heart attack or stroke. We discuss the impact that lifestyle can have on your particular health future.

What is not included in a preventative screening physical? By CPT coding rules, the preventative screening physical cannot include “active management” of a medical problem or symptom unless a separate “office visit” is also coded alongside the screening physical – which will transform the appointment type into a combined visit (described below). Medication refills and dose changes can be included in the preventative screening physical, but new medications, treatment strategies, and referrals (other than screening referrals) trigger CPT codes for “office visit”.

These distinctions are important because some insurance companies waive all out-of-pocket costs for one preventative screening physical appointment per year (i.e., no copay,no co-insurance, no deductible payment). Be sure to ask your insurer if they are one such company. When you schedule a preventative screening physical – with Wise Patient or any other clinic – you should emphasize to the clinic that you are scheduling a preventative screening physical. That way we can do our part to insure the contents of the visit do not include things that would trigger an “office visit” code to be generated and billed out.

Some insurance companies do not cover travel-related appointments. In light of this shortfall, we offer a $50 self pay appointment with one of our medical assistants (no face-to-face time with the MD) who will go over the recommendations for your particular itinerary and have any prescriptions approved by one of our physicians. A physician will review the medical assistant’s recommendations and confirm they are indicated, but will not see you directly. We feel our $50 self pay price is competitive with many of the local pharmacy prices that we have seen.

If your insurance plan does cover pre-travel visits we are happy to send the claim to your insurance company at your request, just let us know!

Our Health Coaches are all certified phlebotomist. If blood work is indicated at your appointment we draw your blood right then and there. However, some tests require you be fasting so we allow patients to book blood-draw only appointments every morning at 8am. We do not offer blood draw appointments for patients who have not seen one of our physicians prior.

Please be aware that any blood tests we think are in your best interest will be sent off to an external facility (Lab Corp or Quest Diagnostics) for the test and the lab will bill your insurance accordingly. We have no control over the prices of those labs as the amount it will cost you depends on your insurance plan.

If you are a Direct Primary Care subscription patient, we offer self pay prices at a fraction of the cost that most insurance companies will charge you.

Vaccinations

We supply the influenza vaccine during the recommended time to get vaccinated (September-April). In addition, we supply the TDAP vaccine (Tetanus, Diphtheria, and Pertussis) and are happy to administer it when indicated. As a small clinic, we do not have the necessary volume to stock any other vaccines and therefore any vaccines you may need can be sent to you local pharmacy for administration.

Preventative Screening Physical CPT codes

Curious about how much your insurance company will cover? Call your insurance company and reference the following CPT codes to find out.

Office Visit CPT codes

Guide to Conducting Healthcare Facility Visits

by Craig Zimring, Ph.D. Georgia Institute of Technology

Published by The Center for Health Design, 1994

INTRODUCTION

A major medical center is building a new diagnostic and treatment center that will include both inpatient services and expensive high technology outpatient services The center is considering whether to provide day surgery within the diagnostic and treatment center or in a freestanding outpatient facility. They are facing a dilemma. If they locate the day surgery center separately, they can use lower-cost construction. If they combine the functions, they can use the spare capacity that will likely become available in the inpatient operating rooms. This is especially important as outpatient procedures become increasingly complex. The center wishes to evaluate sites that currently operate in fully separate facilities versus ones that provide separate outpatient and inpatient reception and recovery facilities, but share operating rooms.

A large interiors firm has been contacted to conduct a visit of several new children’s hospitals in the Northwest. Eager to get the commission from this major hospital corporation to renovate the interior of a large children’s hospital, the firm arranges visits of hospitals it has designed as well as two designed by other firms.

An architecture firm is renovating a large medical laboratory in an existing building which has a minimal 11-foot-3-inch floor-to-floor height. Concerned that the client may not understand the implications of this tight dimension-which means that the fume hood ventilation system can not easily be installed within this space-the architects arrange visits of other labs with similar floor-to-floor heights, change in healthcare and society is rapid and increasingly unpredictable, bringing an unprecedented level of risk for healthcare organizations facing new projects. This guide discusses a specific tool that healthcare organizations and design professionals can use to help manage uncertainty: the facility visit. In almost every healthcare project someone-client, designer, or client-design team-visits other facilities to help them prepare for the project. A probing, well structured, and well run visit can highlight the range of possible design and operational alternatives, pinpoint potential problems, and build a design team that works together effectively over the course of a design project. It can help a team creatively break their existing paradigms for their current project and can provide a pool of experience that can inform other projects. All of these can help reduce risk for healthcare organizations.

However, current facility visits are often ineffective. They are frequently conducted quite casually, despite the rigor of much other healthcare planning and design. Visits are often costly—$40,000 or more-yet they often fall short of their potential. Sites are often chosen without careful consideration, little attention is given to clarifying the purpose or methods of visits, there is often little wrap-up, and frequently no final report is prepared. Not only is the money devoted to the visit frequently not used most effectively, the visit presents important opportunities to learn and to build a design team. These opportunities are too often squandered.

This guide focuses on what a facility field visit can accomplish and suggests ways to achieve these goals. Although a facility visit may occur in a variety of circumstances, including the redesign of the process of healthcare without any redesign of the physical setting, this guide focuses on situations in which architectural or interior design is being contemplated or is in process.

SCOPE OF THE RESEARCH

The goals of this project were to learn about the existing practice of conducting healthcare facility visits, to learn about the potential for extending their rigor and effectiveness, and to develop and test a new approach. We interviewed over 40 professionals in the fields of healthcare and design from every region of the US, including interior designers, architects, and clients who had participated in design projects, and healthcare professionals who conduct visits of their own facilities. We sampled professionals from large and small design firms, and from large and small medical organizations. To get a picture of both “average” and “excellent” practice we randomly selected members from professional organizations such as the AIA Academy on Architecture for Health and the American Society of Hospital Engineers, and augmented these with firms and individuals who were award winners or were recommended to us by top practitioners. We developed a multi-page questionnaire that probed the participants’ experiences with visits, including their reasons for participating, their methods, and how they used the information produced. We faxed each participant the questionnaire, then followed up with an interview on the phone or in person. The interviews averaged about one-and-a-half hours in length. Every person we initially contacted participated in an interview. Everyone in our sample had participated in some sort of visit of healthcare facilities within the past year.

After conducting the interviews we developed, field tested, and revised a new facility visit method, which is presented in this guide. Throughout this process we conferred with select members of the Research Committee of The Center for Health Design and the Project Advisory Board.

GOALS OF FACILITY VISITS

There are many reasons for doing a facility visit and many different kinds of visits. However, visits roughly fall into three categories: specific visits, departmental visits and general visits. Specific visits focus on particular issues such as the design of patient room headwalls, nursing stations, or gift shops; departmental visits focus on learning about the operations and design of whole departments such as outpatient imaging or neonatal intensive care; general visits are concerned with issues relevant to a whole institution, such as how to restructure operations to become patient-focused. Usually, departmental and general visits occur during programming or schematic design; specific visits often occur during design development, when decisions are being made about materials, finishes and equipment.

More broadly, there are several general reasons for conducting visits: learning about state-of-the art facilities; thinking about projects in new ways; and creating an effective design team.

LEARNING ABOUT STATE-OF-THE-ART FACILITIES

Visit participants want to learn what excellent organizations in their field, both competitors and other organizations, are doing. Participants are often particularly interested in learning how changes in business, technology or demographics, such as increased focus on outpatient facilities or increased criticality of inpatients, might affect their own operations and design. For example, in Story 1, below, a UK team was interested in grafting US experience onto a UK healthcare culture. In another example, hospital personnel at Georgia’s St. Joseph’s Hospital visited five emergency rooms over the course of several weeks before implementing an “express” service of their own. According to planner Greg Barker (Jay Farbstein & Associates, CA) they “use site visits as a method of exposing the clients to a broader range of operating philosophies and methods.” This gives the clients and design professionals a common frame of reference on which to base critical operational and design decisions.

William Headley, North Durham Acute Hospitals, UK

Traditionally, hospital design in the UK has been established centrally, with considerable emphasis placed on standard departmental areas and on a standardized planning format known as “Nucleus.” The 20-year-old Nucleus system is based on a standard cruciform template of approximately 1,000 square meters housing a multitude of departments, which can be interlinked to provide the nucleus of a District General Hospital.

Durham wished to develop a hospital that in its vision would meet the challenges of the 21st Century, and produce a custom-designed hospital solution built to suit the needs of the patient, not just individual departments.

The brief has, therefore, to be developed from a blank sheet of paper and not from standard guidelines. It is also the Trust’s objective to have the brief developed by staff from the bottom up. The purpose of the study tour was to allow frontline staff the opportunity to experience new ideas firsthand and talk to their medical counterparts about some of the philosophies of patient-focused care and to input their findings into the briefing process. We acknowledged the differences in the US and UK healthcare systems, but were interested in ensuring that best US practices, including the patient focused approach, facilities design, and the use of state of the art equipment, was studied and subsequently tailored to suit the new North Durham hospital.

THINKING ABOUT A PROJECT IN A NEW WAY

Participants who are currently engaged in a design or planning project are concerned with using visits to advance their own project. They use a visit to analyze innovative ideas and to help open the design team to new ideas. At the same time they are interested in building consensus on a preferred option. In Story 2, below, a hospital serves as a frequent visit host because it shows how special bay designs can be used in neonatal intensive care, and participants can consider how these designs apply to their current project. Other visit organizers see a visit as an opportunity for focusing the team on key decisions that need to be made, or to help the team focus in a systematic way on a range of strategic options and critical constraints. The visit exposes each team member to a variety of ways of accomplishing a similar program of requirements and thus starts the debate on how to achieve the best results for the facility being designed.

Georgia Brogdon, Vice President Operations, Gwinnett Women’s Pavilion, GA

We get visitors at our facility about once per month. Right now the NICU (neonatal intensive care unit) is the most frequently visited location. The main reason is that Ohmeda uses our unit as a showcase for a special design of NICU bays. People want to see it because most think that Hill Rom is the only vendor of this type of equipment.

Early on, we were also one of the only state-of-the-art LDR facilities around. So if people wanted to visit an LDR unit, they had little choice but to come here. Now, however, people come to see us because we are a freestanding yet still attached facility. Over time the visits have evolved away from the design of the facility and more into programming, services, and operational issues.

We give three types of visits: 1) overview visits for lay people who just want to come see the area; 2) functional visits for other hospital people or architects who want to see the LDR design, mother/baby floor, NICU design, etc.; 3) operational flow visits to learn how the LDR concept impacts operations. In general, we start the visitors wherever the patient would start in the facility.

To arrange a successful visit of our facility, we need to know the interests of the visitors; then we can focus the schedule on that. Also knowing who they are bringing is helpful. You need to have their counterparts available. The types of information needed to conduct facility visits are: 1) what specific operational information to ask for in advance-size, number of rooms, number of physicians, staffing, C-section rate, whether they are a trauma center; 2) how to prepare for the visit; 3) who to bring. We’ve found that periodically the visitors are disappointed because they didn’t bring enough people. Better to have too many than not enough.

CREATING AN EFFECTIVE DESIGN TEAM

Participants use visits as an opportunity for team building. Many visits are conducted early in a design project by a team who will work together for several years. The visit provides participants a useful opportunity to get to know each other and to build an effective team. As Story 3 illustrates, clients often look to a visit to see how well designers can understand their needs; designers use it as a way to learn about their clients and to mutually explore new ideas. A visit can also provide an opportunity for medical programmers to work with designers and clients. This is particularly important if programming and design are done by different firms.

Many visit participants focus on interpersonal issues: spending several days with someone helps build a personal relationship that one can rely on during a multi-year project. A visit also provides the opportunity to achieve other aspects of team building: clarifying values, goals, roles and expertise of individual participants; and identifying conflicts early so they can be resolved. One result for some teams is that it establishes a common vocabulary of operational and facility terms translated to the local healthcare facility.

Bing Zillmer, Director Engineering Services, Lutheran Hospital, La Crosse, WI

Conducting a facility field visit is an opportunity to have that one-on-one contact and find out if the architect “walks the talk or talks the walk.” The biggest benefit is in finding out how the visit team of the architectural firm has been assembled: to see their level of participation, and how they have interacted with and listened to the clients and the hosts. What we look for in a consultant is not a “yes man”; we look for someone who knows more about existing facilities than we do. Our key concerns are how the team worked together, how they listened.

Dennis C. Lagatta, Vice President, Ellerbe Becket, Washington, DC

The main reason for conducting a visit is to settle an issue with the client. The clients usually have only two frames of reference: the current facility and the one where they were trained. These two frames of reference are hard to overcome without a visit. We conduct visits to help settle an issue between various groups within the institution. The visit process tends to be a good political way to illustrate a problem or a solution to a problem. A good example is when you have a dispute between critical care physicians and surgeons. Both parties may be unwilling to compromise. Usually a visit will be a good way to defuse this conflict.

James W. Evans, Facilities Director, Heartland Health System, St. Louis, MO

Responding to the question, what kinds of team-building activities were conducted before the actual visit took place? The functional space program stage is where you start building a team. Functional space programming is a narrative of what you want to do. If the programming includes a laboratory or some other specialty area, you would also want to have the consultant (if you are using one) involved in this process. Between blocks and schematics is when you want to go on any visits. By working together and staying together through big and small projects, you develop a lot of rapport and credibility.

Les Saunders, Nix Mann And Associates, Architects, Atlanta, GA

In the case of marketing visits, we try and present our unique abilities to our clients and to get to know each other better, Our visits are generally tailored to what the client group is trying to accomplish. Our functional experts will go on the visit so they can get to know the client and try to enhance “bonding.”

Facility visits allow healthcare organizations and design professionals to address several important trends in healthcare.

• A visit allows a team to understand the experience of stakeholders who they do not currently serve, and to examine the design and operations of facilities that are more customer-oriented.
• Social changes are resulting in some stakeholder groups gaining importance, such as outpatients involved in more complex procedures, higher acuity inpatients, older people, or non-English speakers.
• A visit can provide quantitative and qualitative data that support future decision making.
• Tighter budgets, shorter design and construction schedules and more complex projects are requiring design teams to form more quickly and work more effectively.
• A visit can be an effective tool for building a design team early in a design project.

FALLING SHORT OF THEIR POTENTIAL

In a design project, the client healthcare organization generally pays for a visit, either directly or as a part of design fees. Do healthcare organizations usually get good value for their investment? Do visits generally achieve their ambitious goals of learning about competition and change, moving the design project along, and building teams? We found very different answers. Despite the usual rigor of healthcare planning and programming, many current visits are very casual. Whereas some planners of visits do careful searches of available facilities to fit specific criteria, most choose sites to visit in other ways— sites participants happen to already know because they have been written about in magazines, or sites where there is a contact that someone on the team knows. Though these ways of choosing sites may be appropriate, they raise a question as to whether most participants are visiting the best sites for their purposes.

In many cases visit teams simply do not spend much time structuring the visit. Most teams do not even meet in advance to decide the major foci of the visit. We did not find many groups who use checklists or sets of questions or criteria when they go into the field. Whereas some teams compile the participants’ notes, and one team actually created a videotape in a large project, most teams do not create any kind of written or visual record of their visit. Many teams hold no meeting at the end to discuss the implications of the visit, although many participants felt that they emerged in subsequent programming or design meetings.

Despite the apparent casualness of these visits, designers and clients alike almost without exception felt they were a valuable resource.

Simply visiting a well-run facility can be vivid and exciting. It is fascinating to see how excellent competitors operate, to talk to them and learn of their experience. (It is also an excellent opportunity for administrators and designers to get away from their daily routine and talk to professional counterparts.)

But there are large opportunity costs in the way most current visits are run, and they represent considerable lost value for the healthcare organization, designer, and design project.

COMMON PITFALLS

Opportunity costs of current visits come from several common pitfalls.

LOW EXPECTATIONS LEAD TO LIMITED BENEFITS

Often, participants see field visits as a way to get to know other team members and simply to see other sites, but have no clear idea about what information can be helpful to the project at hand. They don’t think through how the visit can help the goals of their project or organization.

TOO BUSY TO PLAN

The planner of a visit faces multiple problems. Often the visit is seen as a minor part of the job of most participants and doesn’t get much attention in advance; schedules and participants may change at the last minute. In many cases, no one is assigned to develop the overall plan of the visit, and to ask if the major components-choice of sites, choice of issues to investigate, methods for visits, ways of creating and disseminating a report-match the overall goals of the organization and project. This is especially ironic because participants are often advocates of careful planning in other areas.

TOO FOCUSED ON MARKETING

Many visits, and especially designer-client visits, are billed as data gathering but are in fact aimed at marketing. A design firm may literally be marketing services or may be trying to get a client to accept a solution that they have already developed: marketing an idea. This may lead to an attempt to create a perfect situation in the facility being visited, one without rush, bustle, or everyday users and the information they can provide. For designer-client teams, we heard many designers complain that they couldn’t control their clients, that they couldn’t keep them focused on prearranged ideas or keep them limited to prearranged routes. (This is often the result of not enough advance work aimed at understanding what interests the participants have and not enough time spent building common goals.)

CLOSING THE RANGE OF DESIGN OPTIONS TOO EARLY

Many visits occur early in the design process or when an organization is considering significant change, a perfect time to consider new possibilities or address issues and solutions not previously considered. This timing, and the chance to see and discuss new options in a visit, presents an opportunity for a design team to open its range of choices and consider novel or creative alternatives. However, many visit participants feel strong pressures to “already know the answer” when they start the visit. Many designers and consultants feel that their clients do not want them to genuinely explore a range of options, that they were hired because they know the solution. Similarly, some medical professionals establish positions early to avoid seeming foolish or uninformed. As a result, the team may choose sites that bring only confirmation, not surprise, and people will be interviewed who bring a viewpoint that is already well established. This is not simply a matter of the individual personalities of people who set up visits, but rather a problem of the design of teams and the context within which they operate. It is often important for a design firm to show a client the approach it is advocating and for them to jointly explore its suitability for the client’s project. However, if the client expects a designer to know the answer before the process starts, rather than developing it jointly with the client, the designer is forced to use the visit to exhort rather than to investigate.

TOO LITTLE STRUCTURE FOR THE VISIT

Whereas no one likes to be burdened with unnecessary paperwork before or during a visit, it is easy to miss key issues if there is not an effort to establish issues in advance, with a reminder during the visit. Seeing a new place, with lots of activity and complexity, makes it easy to miss some key features. Many team members come back from visits with a clear idea of some irrelevant unique feature such as the sculpture in the hallway, rather than the aspect of the site that was being investigated.

INTERVIEWING THE WRONG PEOPLE

Often, out of organizational procedure or courtesy, a site being visited will assign an administrator or person from public relations to be the primary guide. It is almost always preferable to interview people familiar with the daily operations of the department or site.

MISSING CRITICAL STAKEHOLDERS

Almost every healthcare facility is attempting to become more responsive to customers, both patients and “internal” customers such as staff. Patients often now have a choice of healthcare providers, and staff are costly to replace. Despite these trends, many visits miss some key customer groups such as inpatients, outpatients, visitors, line staff, and maintenance staff. It is very important that these groups or people who have close contact with them be represented in visits.

A DESIGNER PROVIDING TOO MUCH DIRECTION DURING A DESIGNERCLIENT VISIT

In an effort to control the outcome, a designer may attempt to ask most of the questions during interviews. In addition to the problem of focusing exclusively on “selling” ideas described above, clients do not like to feel that their role is usurped.

MISSING OPPORTUNITIES FOR TEAM BUILDING

Teams are most effective when everyone understands the values, goals, expertise and specific roles of others on the team. Teams are also most effective when the team understands the process and resources of the team, the nature of the final product, how the final product will be used: who will evaluate it, and by what criteria the success of the product will be evaluated. Although management consultants routinely recommend making such issues explicit at the beginning of team building, we found few visit teams that deal with these issues directly. Many teams do not even get together before a visit to discuss these issues.

NOT ATTENDING TO CREATING A COMMON LANGUAGE

Multidisciplinary design teams often speak different professional languages and have different interests and values. Designers are used to reading plans and thinking in terms of space and materials; healthcare administrators are used to thinking in terms of words and operational plans. Unless a field visit team is conscious about making links between space and operations, there can be little opportunity to establish agreement.

LACK OF AN ACCESSIBLE VISIT REPORT

Most current visits produce no report at all; some produce at least a compilation of handwritten notes. We heard a repeated problem: no one could remember where they saw a given feature.

CHAPTER 1:  MAJOR TASKS

The healthcare facility visit process has three major phases, divided into specific team tasks that are conducted before, during, and after a visit. These phases, and the 13 major tasks that comprise them, are below. The process we propose is quite straightforward, but compared to most current visits it is more deliberate about defining goals, thinking through what will be observed, preparing a report, and being clear about the implications of the visit for the current design project.

PREPARATION

TASK 1. SUMMARIZE THE DESIGN PROJECT

In this task the project leader or others prepare a brief description of the goals, philosophy, scope, and major constraints overview of the design project that the visit is intended to aid. It should include the shortcomings that the design project is to resolve: space limitations, operational inefficiencies, deferred maintenance, etc.

The overview helps focus the facility visit, and can be provided to the host sites to help them understand the perspective of the visit. This summary should be brief, only a few pages of bulleted items, but should clearly identify the strategic decisions the team is facing. For example, a team may be considering whether to develop a freestanding or attached woman’s pavilion. It is also important to identify key operational questions in the project summary. Focusing on design solutions too early may distract the team from more fundamental questions that need to be resolved. The purpose of the summary is to establish a common understanding of goals, build a common understanding of constraints, and allow the visit hosts to prepare for the visit.

The summary of the design project may focus on several topics:

• How do these critical purposes link to key business imperatives, such as “broadening the base of patients” or “allowing nurses to spend more time delivering patient care”?
• What measurable or observable aspects of the design relate to these key purposes? For example, one team may be interested in whether carpeting leads to increased cleaning costs or increased infection rates; another team may be interested in visitor satisfaction with a self-service gift shop.

Key issues in summarizing the design project:

• It should identify the full range of stakeholders who affect the current design.

Note: Many visits ignore this critical up-front work. Depending on the schedule and scope, the summary can be circulated to the team in advance of the brainstorming meeting.

TASK 2. PREPARE BACKGROUND BRIEF

More than most building types, healthcare facilities have a large body of literature providing descriptions of new trends, research, design guidelines, and post-occupancy evaluations. Many design firms and healthcare organizations have this material in their library or can get it from local universities or medical schools. In this task the visit organizer creates a file of a few key articles or book chapters describing the issue or facility type being visited. These are then distributed to the team, allowing all team members to have at least a minimal current understanding of operations and design.

The team leader also prepares an Issues Worksheet. This is a one-page form that is distributed along with the Background Brief to all members of the visit team prior to their first meeting. (See Figure 2 for a sample Issues Worksheet.) It encourages them to jot down what is important to them, and to discuss issues with their coworkers. It works most effectively when the visit organizer adds some typical issues to help them think through the problem. Participants should be encouraged to bring the Worksheet with them to the team meetings.

Key issues in preparing the Background Brief:

• Providing a few current background articles on the kind of department, facility, or process being visited helps create at least a minimum level of competence for the team and helps establish a common vocabulary prior to the visit.
• The Issues Worksheet, along with the Project Summary and Background Brief, allows participants to develop a picture of the project and to brainstorm ideas.

TASK 3. PREPARE DRAFT WORK PLAN AND BUDGET

Once the team leader or others have summarized the design project and prepared the Background Brief, a draft work plan outlining the major components of the field visits can be prepared. At this stage, it is important to establish a tentative budget for the visit. It is also important to make sure that the major components of the draft work plan, such as choosing visit sites and developing critical issues, match the overall goals of the organization and project. The draft work plan provides a tentative structure for the field visits, which can be modified by other team members.

Key issues in preparing the draft work plan:

TASK 4. CHOOSE AND INVITE PARTICIPANTS

The effectiveness of the team is, of course, most directly related to the nature of the participants. Field visit teams are sometimes chosen for reasons such as politics, or as a reward for good service, rather than for their relevance to the project. For healthcare organizations field visit teams are usually most successful if they mix the decision makers who will be empowered to make design decisions with people who have direct experience in working in the area or department being studied. For design firms, teams are often most successful if they include a principal and the project staff. In both of these cases, the team combines an overall strategic view of the organization and project with an intimate knowledge of operational and design details.

Key issues in choosing participants:

• Participants should be chosen with a clear view of why they need to participate and what their responsibility is in planning, conducting and writing up the visit.
• Site hosts say that teams larger than about seven tend to disrupt their operations.

TASK 5. CONDUCT TEAM ISSUES SESSION

It is usually advisable to hold a team meeting early in the visit planning process to: 1) clarify the purposes and general methods of the field visit; 2) build an effective visit team by clarifying the perspective and role of each participant; 3) ‘identify potential sites, if the visit sites have not already been selected. Some resources and methods to select sites are discussed further in the next section, “Critical Issues in Conducting Facility Visits.”

The issues session is often a “structured brainstorming” meeting aimed at getting a large number of ideas on the table. (This is particularly important during departmental and general visits, and if team members don’t know each other.) The purpose is opening the range of possible issues rather than focusing on a single alternative.

This meeting is typically aimed at building a common sense of purpose for all team members, rather than marketing a preconceived idea. This meeting also serves the purpose of making critical decisions regarding the choice of sites and identifying who at the sites should be contacted.

Each participant should bring his or her Issues Worksheet along to the meeting. The initial task is to get all questions and information needs onto a flip chart pad or board before any prioritization goes on. Then the leader and group can sort these into categories and discuss priorities. These categories and priorities may be sorted in the form of lists which include: 1) a list of critical purposes of the departments or features being designed; 2) a list of critical purposes of the departments or features being evaluated at each facility during visits; 3) a list of existing and innovative design features relevant to these purposes. The critical purposes of the departments or design features at existing facilities can be charted at different spatial levels of the facilities, such as: site, entrance, public spaces, clinical spaces, administrative and support areas. Some typical architectural design issues are provided in the appendix.

The issues session may be run by the leader or the facilitator. Because one of the purposes of this meeting is to get balanced participation, it may be useful to have someone experienced in group process run the meeting, rather than the leader. His or her job is to make sure everyone participates, allowing the leader to focus on content.

This meeting may also provide an early opportunity to identify potential problems in conflicting goals, values or personalities on the team. For instance, a healthcare facility design project may have significant conflicts between departments, or between physicians and administrators. The meeting may also allow the team to agree on basic business imperatives and to be clear about the constraints that are of greatest importance to them, such as “never having radioactive materials cross the path of patients.”

Key points in running an issues session:

• Everyone should be able to participate without feeling “dumb.”
• The leader and group should try to understand the range of interests and priorities represented.
• Brief notes of the meeting should be distributed to all participants.

Note: This meeting is successful if participants feel they can express ideas, interests, and concerns without negative consequences from other members of the team. There is no such thing as a stupid question in this meeting.

TASK 6. IDENTIFY POTENTIAL SITES AND CONFIRM WITH THE TEAM

Based on the work plan which established the visit objectives and the desires, interests and budget of the team, the visit organizer chooses potential sites, and checks with the team. If possible, he or she provides some background information about each site to help the team make decisions.

The team may know of some sites they would like to visit, and these might have emerged in the issues session. Otherwise there are a range of sources for finding appropriate sites to visit: national organizations such as the American Hospital Association, as well as the American Institute of Architects Academy on Architecture for Health Facilities, and a range of magazines that discuss healthcare facilities. (See the section below entitled “Choosing Sites.“)

Different teams pick sites for different reasons. Some may pick a site because it is the best example of an operational approach such as “patient-focused care.” Others may look for diversity within a given set of constraints, such as different basic layouts of 250-bed inpatient facilities.

Many visit leaders complain that the team sometimes is distracted by features outside the focus of the tour, and particularly by poor maintenance. Wherever possible, it is advisable for the visit organizers to tour the site in advance of the group visit and to brief the hosts in person about the purposes of the visit. Although it is rare, some sites now charge for visits.

A key issue in choosing sites:

• The selection of sites should challenge the team to think in new ways.

Note: Sites are often chosen to provide a clear range of choices within a set of constraints provided by operations, budget, or existing conditions, such as “different layouts of express emergency departments” or “different designs of labor-delivery-post-partum-recovery rooms.”

TASK 7. SCHEDULE SITES AND CONFIRM AGENDA

The leader or facilitator calls a representative at each host site to schedule the visit. He or she confirms the purposes of the visit, confirms with the host sites the information needed before and during the field visit, and confirms who will be interviewed at the site. Healthcare facilities are sometimes more responsive to a request for a visit if they are called by a healthcare professional or administrator rather than a designer: if someone on the team knows someone at a site, he or she may want to make the first phone call. Many teams also find that if they arrange for a very brief visit, this may be extended a bit on site when the hosts become engaged with the team. When confirming the schedule for the visit with the host facilities, the visit organizer should specify that the visit team would prefer to interview people familiar with the daily operations of the department or site.

Key issues in scheduling sites:

Note: Sites are often proud of their facilities and often enjoy receiving distinguished visitors. However, they often find it difficult to arrange interviews or assemble detailed information on the spot.

TASK 8. PREPARE FIELD VISIT PACKAGE

Visits are more effective if participants are provided a package of information in advance: information about schedule, accommodations, and contact people; information about each site, including, where possible, brief background information and plans; a simple form for recording information; and a “tickler” list of questions and issues.

a) Prepare visit information package

The organizers should provide participants information about the logistics of the field visit: schedules, reservation confirmation numbers, phone numbers of sites and hotels.

b) Prepare site information package

The site information package orients participants to the site in advance of the visit. Depending on what information is available, it may include: plans and photos of each site; basic organizational information about the site (client name and address, mission statement, patient load, size, date, designers, etc.); description of special features or processes or other items of interest. Whereas measured plans are best, these are not often available. Fire evacuation plans can be used. A sample site information package is provided in the Appendix. Many teams find it useful to review job descriptions for the host site, and many organizations have these readily available.

c) Prepare Visit Worksheet

Facility visits are often overwhelming in the amount of information they present. It is useful for the organizers to provide the participants with a worksheet for taking notes. We have provided a sample worksheet as Figure 3 below, and blank forms are provided in the Appendix. The purpose of the checklist is to remind participants of the key issues and to provide a form that can easily be assembled into the trip report.

Note: A successful worksheet directs participants to the agreed-upon focal issues without burdening them with unnecessary paperwork. Participants should understand the relationship between filling out the checklist and filling out the final report.

FACILITY VISIT

TASK 9. CONDUCT FACILITY FIELD VISIT

The actual site visit typically includes: 1) an initial orientation interview with people at the site familiar with the department or setting being investigated; 2) a touring interview where the team, or part of it, visits the facility being investigated with someone familiar with daily operations, asking questions and observing operations; 3) recording the site; 4) conducting a wrap-up meeting at the site. (Each of these steps is discussed individually below.) The interview sessions are focused on helping the team understand a wider range of implications and possibilities. If appropriate, the wrap-up session may also be used for focusing on key issues that move the design along.

Note: Participants often like to speak to their counterparts: head nurse to head nurse, medical director to medical director, etc., although everyone seems to like to talk to people directly involved with running a facility such as a head nurse. People who know daily operations are often more useful than a high-level administrator or public relations staff member.

a) Conduct site orientation interview

During the orientation interview the visit team meets briefly with a representative of the site to get an overall orientation to the site: layout and general organization; mission and philosophy; brief history and strategic plans; patient load; treatment load; and other descriptions of the site. Many teams are also interested in learning about experiences the healthcare organization had with the process of planning, design, construction and facility management: What steps did they use? What innovations did they come up with? What problems did they encounter? What are they particularly proud of? What do they wish they had done differently?

b) Conduct a touring interview

The touring interview was developed by a building evaluation group in New Zealand and by several other post-occupancy evaluation researchers and practitioners. (See the post-occupancy evaluation section of the Bibliography.) In the touring interview, the team, or a portion of it, visits a portion of the site to understand the design and operations. Conducting an interview in the actual department being discussed often brings a vividness and specificity that may be lacking in an interview held in a meeting room or on the phone. One of the great strengths of the touring interview is the surprises it may bring, and the option it provides to consider new possibilities or to deal with unanticipated problems. As a result, it often works best to start with fairly open-ended questions:

• What works well here? What works less well?
• What are the major goals and operational philosophy of the department?
• What is the flow of patients, staff, visitors, meals, supplies, records, laundry, trash?
• Can they demonstrate a sample process or procedure, such as how a patient moves from the waiting room to gowning area to treatment area?
• What are they most proud of?
• What would they do differently if they could do it over?

These questions also provide a nonthreatening way to discuss shortcomings or issues that are potentially controversial. The team may then want to focus on the specific concerns that were raised in the issues session.

A difficult, but critically important, thing to avoid in a touring interview is to become distracted by idiosyncratic details of the site being visited. Often operational patterns or philosophy are more important than specific design features that will not be generalized to a new project: how equipment is allocated to labor-delivery-recovery-postpartum rooms in the site being visited may be more important than the color scheme, even though the color may be more striking.

Large multidisciplinary teams are particularly hard to manage during a touring interview. A given facility may have a state-of-the-art imaging department that is of great interest to the radiologists on the team but may have a mediocre rehabilitation department. In these cases, some of the touring interviews may be focused on “what the host would do differently next time.”

Key issues in conducting the touring interview:

Note: It is important to include people familiar with daily operations on the touring interview, both on the team side and on the side of the site being visited. A frequent problem is that some stakeholder groups such as patients or visitors are not represented; special efforts should be taken to understand the perspectives of these groups.

c) Document the visit

The goals of the visit dictate the kinds of documentation that are appropriate. However, most visits call for a visual record, sketches, and written notes.

In most cases it is useful to designate one or more “official” recorders who will assemble notes and be sure photos are taken, measurements made, plans and documents procured, etc. For designer-client visits, it is often useful to have at least two official recorders to look after both design and operational concerns. However, because a team often splits up, most or all participants may need to keep notes.

It is quite rare for teams to use video to record their visit, although this seems to be increasing in popularity. Editing videos can be very costly: it may take a staff member several person-days in a professional editing facility to edit several hours of raw video down to a 10- or 15- minute length. However, this time may be reduced with the increased availability of inexpensive microcomputer-based editing programs.

Key issues in recording the facility:

Many departmental and general visit teams find it useful to photographically record key flows, such as patients, staff and supplies, and location of waiting rooms and other patient amenities.

Note: If the method of creating the documentation is established in advance it can easily be assembled into a draft report.

d) Conduct on-site wrap-up meeting

Whereas the visit interview is focused on opening options for the team and identifying new problems and issues, the wrap-up meeting is often more focused on clarifying how lessons learned on the visit relate to the design project, and how they begin to answer the questions the team established. It is often useful to have a representative of the host site present at the wrap-up meeting to answer questions, if their time allows.

Key issues in conducting wrap-up meetings:

TASK 10. ASSEMBLE DRAFT VISIT REPORT

A draft visit report may take many different formats. The simplest is to photocopy and assemble all participants’ worksheets and notes, retyping where necessary. Alternatively, the organizers or a portion of the team may edit and synthesize the worksheets and notes. Though more time consuming, this usually results in a more readable report. A somewhat more sophisticated version is to establish a database record that resembles the form used to take notes on-site in a program such as FoxPro, Dbase, or FileMaker Pro. Participants’ comments can be typed into the database and sketches and graphics can be scanned in and attached.

These are then provided to all participants.

A key issue in assembling the draft report:

• Simplicity is often best; simply photocopying or retyping notes is often adequate, especially if photos and sketches are attached.

TASK 11. CONDUCT FOCUS MEETING

Upon returning home, the team conducts a meeting to review the draft trip report and to ask:

Unlike the issues session held early in the visit planning process, which was primarily concerned with bringing out a wide range of goals and options, this meeting is typically more aimed at establishing consensus about directions for the project.

A key issue in conducting the focus meeting:

• The purpose of the focus meeting is to establish the lessons learned for the design project.

Note: The leader should carefully consider who is invited to the focus meeting. This may include others from the design firm, consultants, healthcare organization, or even representatives from the site.

TASK 12. PREPARE FOCUS REPORT

The focus report briefly summarizes the key conclusions of the visit for the visit team and for later use by the entire design team. It is an executive summary of the visit report which may provide a number of pages of observations and interview notes.

Key issues in preparing the focus report:

• The focus report should be a clear, brief, jargon-free summary.

TASK 13. USE DATA TO INFORM DESIGN

The key purpose of a facility visit is to inform design. Whereas this can occur informally in subsequent conversations and team meetings, it is best achieved by also being proactive. For example, the team can:

Key issues in using data to inform design:

• Reports and materials collected on visits should be available to all participants in the design process and should be on hand during subsequent meetings. A central archive of materials should be available and should be indexed to allow easy access for people involved in future projects.

CHAPTER 2:  TOOL KIT

TASK CHECKLIST

The team leader prepares a brief summary of the goals, philosophy, scope, and major constraints of the design project to help focus the field visit.

• Prepare a list of design or operational features related to these critical purposes.

The team leader prepares a file of a few key articles or book chapters that provide descriptions of new trends, research, design guidelines and post-occupancy evaluations of the facility type, department or issue being studied. He or she also prepares Issues Worksheets for team members to make notes on prior to the initial issues brainstorming session.

• Assemble current literature on existing facilities. Prepare the Issues Worksheet.

The draft work plan clarifies the values, goals, process, schedule and resources of the visits.

In this task the team leader builds a team. The ideal team combines a view of the overall strategic perspective of the organization and project with an intimate knowledge of daily operations.

The team issues session has three purposes: 1) clarify the purposes and general methods for the field visit; 2) build an effective team; 3) identify potential sites. The issues session is often a “structured brainstorming” meeting aimed at getting a large number of ideas on the table, and at understanding the various perspectives of the team.

• Clarify the resources available to the team and the use of the information collected.

TASK 6. IDENTIFY POTENTIAL SITES AND START FACILlTY VISIT PACKAGE

Based on visit objectives and the desires, interests and budget of the team, the visit organizers choose potential sites and check with the team. If possible they provide some background information about each site.

• If field investigation sites are already selected, provide fact sheets about each site to the participants.

In this task, the purposes and schedule of the visit are confirmed with the sites. This should occur at least two weeks before the visit.

The field investigation package includes the following components, which are used for conducting the visit:

• Tour information package (tour itineraries, transportation and accommodation details, list of contact people at each facility).
• Site information package (description of the sites, background information, facility plans).
• Site Visit Worksheets for notetaking.

TASK 9. CONDUCT FIELD VISIT

The interview sessions are focused on opening: helping the team understand a wider range of implications and possibilities. If appropriate, the wrap-up session may also be used for focusing on key issues that move the design along. Conduct site orientation interview.

• Collect any additional information from the host site.
• Conduct touring interview with people familiar with daily operations and a range of stakeholders.
• Document the visit through notes, sketches and photos.
• Conduct on-site wrap-up meeting with team members.

The draft report is a straightforward document allowing others to benefit from the investigation and providing the team a common document to work from.

The team conducts a focus meeting to ask: What are the major lessons of the investigation? What does it tell the team about the current project?

The Focus Report briefly summarizes the key conclusions of the visit for the visit team and for later use by the entire design team. It is an executive summary of the Visit Report which may provide a number of pages of observations and interview notes.

• Prepare and distribute a brief Focus Report.

The purpose of this document is to inform the design process.

• Write a brief newsletter about the design project that includes key findings from the visit.

SAMPLE FACILITY FACT SHEET (see PDF version)

CHAPTER 3:  CRITICAL ISSUES IN CONDUCTING FACILITY VISITS

Selecting visit sites.

One of the most important steps in conducting healthcare facility visits is the selection of appropriate sites. However, there is no single source of information on healthcare facilities, and site selection is not an easy task. It is difficult to locate sites with comparable features in terms of workload, size, budget, operational facilities and physical features. Without this information, the tendency is to choose sites based on other criteria, such as location and proximity, or the presence of a friend or former coworker at specific host facilities.

However, depending on the nature of the facility visit, there are several resources that can be consulted for site selection. Some healthcare and design professional associations periodically publish guides and reference books which are helpful in selecting sites for facility visits. The following sources can be referred to before selecting specific facilities for field visits:

NATIONAL HEALTHCARE ASSOCIATIONS

American Hospital Association (AHA) AHA Resource Center, Chicago, (312) 280-6000

AHA database for healthcare facilities in the state of Missouri. : Missouri Hospitals Profile . Listed price: $27.50.

AHA Guide to locating healthcare facilities in the US . The listed facilities are classified according to the city/county with a coded format for the number of beds, admission fee, etc. Listed price: $195 for nonmembers and $75 for members.

AHA Health Care Construction Database Survey . Contact Robert Zank at the AHA Division of Health Facilities Management, (312) 280-5910.

Association of Health Facilities Survey Agency (AHFSA) Directory of the Association of Health Facilities Survey Agency. AHFSA, Springfield, IL.

National Association of Health Data Organizations (NAHDO) Some states collect detailed hospital-level data. To obtain information on states with legislative mandates to gather hospital-level data, contact Stacey Carman at 254 B N. Washington Street, Falls Church, VA 22046-4517, Telephone: (703) 532-3282, FAX: (703) 5323593.

NATIONAL ASSOCIATIONS FOR DESIGN PROFESSIONALS

American Institute of Architects (AIA) AIA Academy on Architecture for Health 1735 New York Avenue NW Washington, DC 20006

(202) 626-7493 or (202) 626-7366, FAX (202) 626-7587 To order AIA publications: (800) 365-2724

Hospital Interior Architect .

Hospital and Health Care Facilities, 1992. Listed price: $48.50 for nonmembers; 10% discount for members off listed price.

Hospitals and Health Systems Review, July 1994. Listed price: $12.95 for nonmembers; 30 % discount for members off listed price.

Hospital Planning . Listed price: $37.50 for nonmembers; 10% discount for members off listed price.

Hospital Special Care Facility , 1993.

Organizational Change: Transforming Today’s Hospitals, January 1995: Listed price: $36.00 for nonmembers; 30% discount for members off listed price.

Health Facilities Review (biannual), 1993. Listed price: $20 for nonmembers; $14 for members.

PERIODICALS DESCRIBING SPECIFIC HEALTHCARE FACILITIES

Modern Healthcare. This national weekly business news magazine for healthcare management is published by Crain Communication, and holds annual design awards. In conjunction with AIA Academy of Architecture for Health, this periodical announces annual competition and honors architectural projects that build on changes in healthcare delivery. Contact Joan Fitzgerald or Mary Chamberlain at 740 N. Rush Street, Chicago IL 60611-2590, (312) 649-5355.

American Hospital Association Exhibition of Architecture for Health , 1993.

For further information contact Robert Zank at the Division of Health Facilities Management, (312) 280-5910.

Journal of Healthcare Design . This journal illustrates 20-40 exemplary healthcare facilities in each

annual issue. Free list of previously-toured exemplary facilities (available by calling The Center).

Æsclepius . Æsclepius is a newsletter discussing a range of design issues relevant to healthcare facilities.

TEAMBUILDING

Many people who conduct healthcare facility field visits use them as a way to build an ongoing design team. This is particularly true of designer-client-consultant teams who conduct visits early in a design project. According to organizational researcher and consultant J. Richard Hackman, 1 teams often spend too much time worrying about the “feelgood” aspects of interpersonal relationships and not enough time focusing on other key issues such as choosing the right people for the team, making roles and resources clear, specifying final products, and clarifying how the final product will be used.

Participants are often chosen because they are upper-level administrators or because they deserve the perk. It may not be clear what their function is on the visit or how they would contribute to any later decision making about the design project. Likewise, visit teams often don’t know what resources are available to them: Can they visit national sites? Can they call on others to help prepare and distribute a visit report?

• Some key team building steps include:
• Select visit participants with a clear idea of why they are participating and how they can contribute.
• Keep the team small; visit teams of more than seven or eight people are hard to manage.
• Provide each participant a clear role before, during and after the actual site visit, and negotiate this role to fit their interests and skills. Roles should be clearly differentiated and clear to all participants.
• Make the final product clear: simple photocopying and assembly of notes and photos taken during the visit; brief illustrated written report; videotape, etc.
• Clarify how the visit findings are to be used: what key decisions are the major focus?

ROLES IN CONDUCTING FACILITY VISITS

There are several key roles in the process. Depending on the size of the team and the nature of the visit, each role may be taken on by a different person, or they may be combined.

LEADERSHIP TASKS:

• Restate current need and parameters of the design project.
• Develop some background information on the issues or setting types being investigated, and distribute to team members.
• Conduct a brainstorming meeting to understand the expertise, interests, values, and goals of each team member.
• Identify potential visit team members, and invite them.
• Summarize the goals of the design project, clarify how the field visit might advance these goals, and communicate these to the team.
• Identify roles for each team member.
• Develop a work plan and budget.
• Clarify the criteria for choosing sites.
• Prepare and/or review major documents: site-specific protocols; checklists and lists of questions and issues; information about each site being visited; overall plan for the visit; visit report; focus report.
• Conduct wrap-up meeting at each site.
• Conduct focus meeting on returning home.

SUPPORT TASKS:

• Assemble a few key articles or other documents to help the team understand the key issues in the setting types, processes or departments being visited.
• Identify potential sites, with some information about each site candidate so the leader and team can make final choices.
• Confirm with sites, and clarify what information the team will need in advance and what will be collected during the visit.
• Prepare draft materials (Background Brief, site information package, visit information, interview protocol) for review by the leader.
• Organize any trip logistics that are not done individually by participants: car rentals, hotel reservations, air tickets, etc.
• Write thank-you letters to site participants.
• Prepare a Draft Visit Report for review by the leader and team.
• Draft a Focus Report for review by the leader and the team.

FACILITATION TASKS:

When the team is attempting to get broad input into the process, such as when the team meets initially to set direction, it is often useful to have someone run the meeting who has the role of simply looking after the process of the meeting, rather than the content. He or she is charged with making sure that everyone is heard without prejudice, and that all positions are brought out. It often works poorly to have a senior manager in this role. Even if he or she has good facilitation skills, it is intimidating for many people to speak up in a meeting led by their boss.

Specific tasks:

• Conduct the initial brainstorming session that establishes the direction, issues and roles for the visit.
• Conduct any additional sessions where balanced participation is important to increasing the pool of ideas or getting “buy-in” from all team members.

RECORDER TASKS:

During the actual site visit, one or more people are typically charged with maintaining the “official” records of the visit (individuals may keep their own notes as well). This may include written notes, audio or video records, or photographs. If the team breaks up during the visit, a recorder should accompany each group.

Specific tasks include:

• Procure any required recording devices and supplies, such as cameras, tape recorders, paper forms, etc.
• Make records during the visit.
• Edit the record and assemble into a report.

TEAM PARTICIPANTS TASKS:

INTERVIEWING

Interviews vary greatly in the amount of control exercised by the interviewer in choosing the topic for discussion and in structuring the response. An intermediate level of control over topic and responses, often called a “structured interview,” is usually appropriate in a facility visit. In a structured interview, the interviewer has an interview schedule which is a detailed list of questions or issues which serves as a general map of the discussion. However, the interviewer allows the respondent to answer in his or her own words and to follow his or her own order of questioning if desired. The interview is usually aided by walking through the setting or by having plans or other visual aids during seated sessions.

The use of fixed responses, in which respondents have to choose a “best” alternative among several presented, allows rapid analysis of results and may be appropriate if a large number of people are interviewed during a visit. The cost-effectiveness of interviews needs to be considered by the architect or manager when designing the process. Individual interviews are useful because people being questioned may be more forthcoming than if friends or colleagues are present.

However, individual interviews are expensive. With scheduling, waiting time, running the interview, and coding, a brief individual interview may involve several hours or more of staff time.

In summary, interviews are valuable because people can directly communicate their feelings, motives and actions. However, interviews are limited by people’s desire to be socially desirable or by their faulty memories, although these problems may not be too serious unless the questions are very sensitive.

CHAPTER 4:  CONCLUSIONS

Unfortunately, many design processes do not do a good job at controlling risks, costs, and inefficiencies. A design project may have a big influence on the future of an organization, but critical operational and design decisions often receive too little attention. And problems or new ideas are often discovered very late in a design process, when they are difficult and costly to accommodate. It is not hard to understand the source of these difficulties. The crises of everyday life go on unabated during design and distract people from design, short-term politics continue, and many people are comfortable with what they already know. Many design team participants representing healthcare organizations want to reproduce their existing operation, even if they can recognize its flaws.

A healthcare design team is too often more like a raucous international meeting than like an effective task-oriented organization. Participants speak different professional languages, have different experiences, have different short-term objectives, hold different motivations for participating, and hold different values about what constitutes a successful project. The team may be far into a project before it understands the different viewpoints represented on the team.

A facility visit is a unique opportunity to address some of these problems. It provides an extended opportunity for a design or planning team to get together outside the pressures of daily life, to critically examine the operations of an excellent facility, to rethink its own ideas, and to build the basis of a team that may function for several years. It is often the longest uninterrupted time a team ever spends together, and the best chance to think in new ways.

A visit has three goals: to establish a situation for effective critical examination of state-of-the-art operations and facilities; to think about the project in new ways; and building a team. These goals are intertwined. A well-structured facility visit may help build a team more effectively than an artificial “feel-good” exercise of mountain climbing or simulated war games. A team that looks at a facility from different perspectives, and in which participants forcefully argue their viewpoint based on evidence from a common visit, can learn each other’s strengths, preferences, and priorities quickly and in a way that builds a bond that is closely related to their own project.

Many teams, however, do not provide enough structure for either critical examination or team building. Critical examination requires an understanding of what key issues are to be examined and how they might apply to the current design problem. Team building requires that a team clearly establishes the role of each team member, makes the resources, process, and schedule clear, is explicit about the form and use of the final report, and establishes a common language.

Healthcare designers and consultants can develop better facility visits, but the responsibility for improving this practice rests with healthcare clients. For a visit to reach its potential, clients must demand an improved process, hold the organizer accountable-and be willing to pay for it. The healthcare client must see design and planning as a process open to mutual learning, and make it happen.

APPENDIX A: BIBLIOGRAPHY

See PDF version for bibliography.

APPENDIX B: EXEMPLARY MICRO-CASES

See PDF version for micro-cases.

Copyright © 1994 by The Center for Health Design, Inc. All rights reserved. No part of this work covered by the copyright herein may be reproduced by any means or used in any form without written permission of the publisher.

The views and methods expressed by the authors do not necessarily reflect the opinions of The Center for Health Design, or its Board, or staff.

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• Premium Statistic Gross output of ambulatory health care services 1998-2022
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• Basic Statistic Total employer firm revenue in ambulatory health care services 2001-2022
• Basic Statistic Revenue in U.S. ambulatory health care service sector by tax category 2001-2021
• Basic Statistic Total tax-exempt employer firm expenses in ambulatory health care services

Industry revenue of out-patient care centers

• Premium Statistic Industry revenue of “out-patient care centres“ in the U.S. 2012-2024
• Basic Statistic Total employer firm revenue of outpatient care centers 2010-2021
• Basic Statistic Employer firm revenue of outpatient care centers by tax category 2004-2010
• Premium Statistic Tax-exempt employer firm expenses of outpatient care centers
• Premium Statistic Revenue of emergency & other outpatient care centers in the U.S., 2009-2014
• Premium Statistic Health center patient distribution in the U.S. 2020, by age group
• Basic Statistic Health center patients in U.S. 2020, by income status
• Premium Statistic Community health center visit in the U.S. 2020, by age and gender
• Premium Statistic Number of community health center visits in the U.S. 2020, by ethnicity or race
• Premium Statistic Community health center visits in the U.S. 2020, by visit reason
• Premium Statistic Community health center visit in the U.S. 2020, by payment source
• Basic Statistic Uninsured patients served by health centers in the U.S. 2020, by state
• Premium Statistic Special populations served by health centers in U.S. 2021
• Premium Statistic Community health center visits in the U.S. 2020, by provided service
• Premium Statistic Community health center visits in the U.S. 2020, by initial diagnosis
• Premium Statistic Community health center visit in the U.S. 2020, by chronic condition presence
• Premium Statistic Community health center visit in the U.S. 2020, by chronic condition
• Premium Statistic Most frequently mentioned drugs named in community health centers in the U.S 2020

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Kate Middleton’s cancer timeline: Diagnosis, treatment and the latest updates from the palace

As the former Kate Middleton continues her treatment for cancer, she will not be able to attend an upcoming military ceremony, which she would've participated in had she not been experiencing health problems.

Kensington Palace confirmed in a statement to NBC News on May 30 that the Princess of Wales will not be in attendance at June 8's Colonel Review, where she normally would have carried out the role of inspecting officer, since she has the honorary rank of Col. in Chief of the Irish Guards.

“This year General James Bucknall K.C.B., C.V.O will carry out the role of Inspecting Officer on behalf of HRH The Princess of Wales at Colonel’s Review as she continues her recovery," the palace said.

Catherine, Princess of Wales, revealed in March that she had been diagnosed with cancer and was undergoing treatment. The cancer was discovered when she underwent a planned abdominal surgery in January. The mother of three, 42, has not taken on any public-facing royal duties since late 2023.

The last official update on the Princess of Wales' recovery came from a senior palace aid on May 22, who told NBC News that she's not yet returning to her royal duties, despite being lightly involved a new initiative about early childhood in the U.K.

"She will return to work when she has the green light from her doctors," the aid said. "She needs her space and the privacy to recover right now."

The Royal Foundation Business Taskforce for Early Childhood released a report earlier in May, and the future queen took time to review it, according to a spokesperson.

"Early childhood is a huge priority for the Princess and so she has been kept fully updated throughout the development of the Taskforce’s work, and she has seen the report," they said.

A few weeks prior, Catherine's husband, Prince William, had a quick exchange during an appearance where he shared a vague update on his wife's health. He was visiting St. Mary’s Community Hospital in the U.K. earlier in May, when a hospital administrator reportedly asked him about Kate.

“He said, ‘She’s doing well, thanks,’” hospital administrator Tracy Smith told reporters, according to the Associated Press .

Here's what we know about her cancer diagnosis and treatment.

Kate Middleton's cancer diagnosis

The princess of Wales said that she was in the “early stages” of preventative chemotherapy after being diagnosed with cancer, she announced March 22, 2024, in a video statement. She did not specify the kind of cancer.

The diagnosis came after Kate underwent major abdominal surgery in January. “At the time, it was thought that my condition was noncancerous," she said in the video. "The surgery was successful. However, tests after the operation found cancer had been present.”

Kate’s video marked her first address since the abdominal surgery.

Kate added that the news of her cancer diagnosis came as a “huge shock,” noting that she and William were aiming to “manage this privately for the sake of our young family.”

“As you can imagine, this has taken time. It has taken me time to recover from major surgery in order to start my treatment,” she said. “But, most importantly, it has taken us time to explain everything to George, Charlotte and Louis in a way that is appropriate for them, and to reassure them that I am going to be OK.”

The princess assured viewers in the video that she is “well and getting stronger every day.” She also asked for “time, space and privacy” as she undergoes treatment and said she is focused on making a “full recovery.”

Kate is the second member of the royal family to face significant health issues this year.

Buckingham Palace announced Feb. 5 that King Charles III was diagnosed with cancer after undergoing a procedure for benign prostate enlargement. The palace did not specify what kind of cancer but clarified it was not prostate cancer.

Kate Middleton's abdominal surgery

On Jan. 16, 2024, Kate underwent a planned abdominal surgery.

In the statement , released the following day, Kensington Palace wrote: “The surgery was successful and it is expected that she will remain in hospital for ten to fourteen days, before returning home to continue her recovery. Based on the current medical advice, she is unlikely to return to public duties until after Easter.”

The statement went on to say that it would only provide updates that were "significant" and to apologize on behalf of the princess, who had to postpone all upcoming engagements.

Catherine returned home to Windsor to continue to recover on Jan. 29, according to a palace statement , which added, "She is making good progress.”

At the time, a palace source told NBC News that she was expected to be recuperating for two to three months following the surgery.

“She looks forward to reinstating as many as possible, as soon as possible,” the statement said.

A Kensington Palace source told NBC News in mid-January that William would be postponing appearances in the coming months and not conduct any official duties while his wife was in the hospital or immediately after she returned home.

For weeks after the surgery and before her cancer diagnosis was revealed, speculation, rumors and conspiracies theories swirled around the wellbeing of the future queen.

The palace has yet to reveal what the abdominal surgery was meant to address.

What type of cancer does Kate Middleton have?

In her video statement, the princess did not specify what kind of cancer she is undergoing treatment for. She shared that it was discovered after an abdominal surgery in January.

The most common types of cancer discovered through abdominal surgery are gastrointestinal, such as colon or stomach, or genital or urinary, Dr. Ben Ho Park, director of precision oncology at Vanderbilt School of Medicine, tells  TODAY.com . He was sure to point out, however, that “it could be anything.”

What is preventive chemotherapy?

Kate specified in her video that her treatment involves " a course of preventative chemotherapy." While not a clinical term, Park says preventive, technically called adjuvant chemotherapy, likely refers to a treatment that is conducted after any initial interventions, such as surgery, to prevent cancer from returning.

Clinical trials have found that chemotherapy after initial treatment, such as surgery, which Kate had, can reduce the risk of the cancer recurring, Park said.

“Even though the surgeons have removed everything they can see, there could still be cancer cells floating around in the body that, if left untreated, may come back later (and) is then incurable,” Park, who does not have details about Kate's specific condition, says.

Park said the purpose of preventive chemotherapy is “trying to maximize” the treatment a patient has already received to eliminate all of the cancer cells.

Preventive chemotherapy typically lasts between three and six months, Dr. Tara Narula, NBC medical contributor, said in a March 25 TODAY appearance.

“When we say the term ‘preventive,’ it sounds light and fluffy, but she may be going through a lot this time,” Narula notes. “This is not a walk in the park,” said Narula. Kate’s age might help her better tolerate treatment but that’s not a sure thing.

Will Kate be returning to her royal duties?

Catherine has not yet returned to her royal duties since announcing her cancer diagnosis.

When her diagnosis was revealed in March, the palace said in an official statement: “The Princess will return to official duties when she is cleared to do so by her medical team. She is in good spirits and is focused on making a full recovery.”

A timeline of Kate Middleton's health

December 2023.

The princess’s most recent public appearance with husband Prince William and their three children — George, 10, Charlotte, 8, and Louis, 5 — came in late 2023 during their  annual Christmas church outing  at the Church of St. Mary Magdalene in Sandringham, near one of the king’s royal estates.

January 2024

Kensington Palace announced that Kate had undergone “planned abdominal surgery” on Jan. 16.

William was by his wife’s bedside during a visit to the hospital on Jan. 18. Kate was discharged from London Clinic, a private hospital, on Jan. 29, 13 days after the procedure took place.

At the time, the palace said that Kate would be recuperating for two to three months after her surgery (before her cancer diagnosis) and that William would be postponing appearances in the coming months while his wife recovered.

Catherine previously experienced health complications during each of her three pregnancies. She had to be  treated in the hospital for hyperemesis gravidarum , a severe type of morning sickness, when she was pregnant with the couple’s oldest child, George, and also had the condition with Charlotte and Louis.

February 2024

William pulled out of attending his godfather’s memorial service due to a “personal matter.” In a statement to NBC News on Feb. 27, the palace wouldn’t elaborate on the reason for William’s absence but said Kate “continues to be doing well.”

After releasing Kate’s video, Kensington Palace confirmed that the prince did not attend the service due to his wife’s cancer diagnosis.

In late February, as rumors about Kate's health and whereabouts mounted, the palace issued another statement about her recovery, explaining that her absence from the public eye shouldn’t be unexpected.

“Kensington Palace made it clear in January the timelines of the Princess’ recovery and we’d only be providing significant updates,” a spokesperson for the princess said in a statement to NBC News on Feb. 29. “That guidance stands.”

The first photo of Kate since the surgery was released March 5. Grainy images showed her in the passenger seat of a black SUV that appeared to be driven by her mother near Windsor Castle. The palace declined to comment on these photos.

A photo , posted on social media in honor of U.K. Mother’s Day on March 10, was the first official one released of Catherine since the surgery. According to the palace, it was taken by William the week prior.

It showed Kate with her three children. Alongside it, she also shared her first message since the procedure: “Thank you for your kind wishes and continued support over the last two months. Wishing everyone a Happy Mother’s Day.”

But within several hours of the photo being shared, it was retracted by major news agencies, including the Associated Press and Reuters, due to “manipulation.”

Kate addressed the controversy in a post on X, writing , “Like many amateur photographers, I do occasionally experiment with editing. I wanted to express my apologies for any confusion the family photograph we shared yesterday caused. I hope everyone celebrating had a very happy Mother’s Day. C.”

The AP explained its decision to retract the photo in a statement to NBC News: “The Associated Press initially published the photo, which was issued by Kensington Palace. The AP later retracted the image because at closer inspection, it appears that the source had manipulated the image in a way that did not meet AP’s photo standards. The photo shows an inconsistency in the alignment of Princess Charlotte’s left hand.”

Reuters issued a similar editor’s note, withdrawing the image after “a post publication review.”

The editing controversy and lack of information about her whereabouts led to viral conspiracies about the princess and the royal family.

Later that month, some social media users speculated a March 11 photograph of Kate and William leaving their Windsor Castle residence was photoshopped. (A royal spokesperson confirmed at the time that they were attending a “private appointment.”)

But the agency that distributed it, Goff Photos, told TODAY.com in a statement that it was only “cropped and lightened, nothing has been doctored!”

On March 18, a video reportedly of Kate and William at a market in Windsor taken over the weekend began to circulate online. Kensington Palace declined to comment on the footage.

William, the prince of Wales, returned to royal duties in mid-April. An April 16 statement released by the Palace said that on April 18, the prince was due to visit Surplus to Supper, “a surplus food redistribution charity, where he will see how surplus food from across the local area is delivered, sorted and re-packaged for delivery to small community (organizations),” the statement read.

He also traveled to West London to visit a youth center that receives these meals.

These visits mark the first official engagements for the prince since Kate announced she was undergoing treatment.

His public comments on his wife's health have been minimal, but in a May 10 appearance, he reportedly said she's "doing well."

Maddie Ellis is a weekend editor at TODAY Digital.

Scott Stump is a trending reporter and the writer of the daily newsletter This is TODAY (which you should subscribe to here! ) that brings the day's news, health tips, parenting stories, recipes and a daily delight right to your inbox. He has been a regular contributor for TODAY.com since 2011, producing features and news for pop culture, parents, politics, health, style, food and pretty much everything else. 

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What does the increasing recognition of Palestinian statehood mean?

Norway, Ireland and Spain announce they will recognise an independent Palestinian state.

Until now, most Western countries have maintained they will formally recognise Palestinian statehood only at the end of a peace process with Israel.

After more than seven months of Israel’s devastating war on Gaza, Norway, Spain and the Republic of Ireland say they won’t wait any longer.

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But the European Union is divided on the issue and larger powers like France say it’s not the right time to recognise a Palestinian state.

And a United States veto still holds back Palestine’s bid to gain full membership at the United Nations.

Will other European nations follow Norway, Ireland and Spain?

And what do the announcements mean for Palestine’s efforts to become a full member of the United Nations?

Presenter: Cyril Vanier

Yossi Beilin – Former Israeli Cabinet minister

Julien Barnes-Dacey – Director of the Middle East and North Africa programme at the European Council on Foreign Relations

Carne Ross – Founder of Independent Diplomat, a not-for-profit advisory group