Chapter 6: Accessible Physical Structures and Features

When implementing any new accessibility initiative at your organization, gaining buy-in from leadership is essential. Building a new facility or re-modeling, designing, or configuring an existing one often requires significant capital costs compared to other initiatives. Leadership support at the organization and location levels are critical to secure necessary approvals.

Actions and Tasks

1. Identify what types of leadership support and buy-in you will need.
   • What type of buy-in from organization- or system-level leadership do you need?
   • Who will view plans or ultimately approve of your project at the clinic/department/facility level?
   • For organizations with multiple facilities, who might you need to secure buy-in from at each? For example, for large health systems, you may need to secure buy-in from each hospital’s CEO.
2. Identify potential champions across your organization. Often, champions are individuals who work in disability specific disciplines (e.g., rehabilitation), are people with disabilities, or are people who have family members with disabilities.
3. Identify how prioritizing accessible built environments will fit within your organization’s existing priorities and initiatives (e.g., accessibility program, health equity, quality and safety, patient experience goals, etc.).
4. Work with your legal team to identify which version of the ADA Standards apply to your facility(ies). Determine if your organization is involved in other relevant regulatory initiatives (e.g., Joint Commission Accreditation, state-level requirements, etc.)
5. Identify potential concerns leadership may have (e.g., cost, construction, disruptions to operations) and possible solutions.
6. Identify upcoming departmental capital improvement or new construction projects. Locate internal funding request deadlines and create timelines to prepare for budget requests when needed.
7. Create necessary charters, strategic plans, and presentations to present to leadership to garner their support.

Materials and Resources

• Appendix 0.3: Federal Requirements↗
• Appendix 0.10 Leadership Support: Key Individuals↗
• Appendix 6.5: Physical Structures Costs and Funding
• U.S. DOJ Access to Medical Care for Individuals with Mobility Disabilities↗

*Appendices 0.3 and 0.10 can be accessed in the General Resources chapter.

The implementation team will be responsible for designing, leading, and monitoring physical accessibility project(s). Your team must include people across different departments and units in order to secure necessary approvals—modifying the built environment will have clinical, operational, facilities, and compliance implications.

Actions and Tasks

1. Identify the implementation team for evaluating the accessibility of existing facilities, planning and executing barrier removal, installation of accessibility features, remodels, renovations, or new construction projects, and monitoring compliance over time.
   • Include people across different departments and units within your organization.
   • Include leadership and others who have the authority to make changes and approve expenditures.
   • Include staff working in these spaces; they know their clinic environment and how patients best move and navigate within the space best.
   • Start with a team at a pilot site or single clinic to work through challenges before managing several projects at once.

2. Determine how you will include patient perspectives. People with disabilities will identify high-priority spaces with significant barriers beyond the ADA checklist.
   • Will you include people with disabilities on your implementation team?
   • Will you convene a patient advisory board?
   • Will you conduct a patient experience survey with accessibility questions?
   • Will you engage disability community organizations?
3. Determine the implementation team meeting structure.
   • How often will the team meet?
   • Is this a project that will be part of an existing capital planning, procurement, or facilities team? Or embedded within another team?
4. Identify champion(s) for the project. Consider including both a clinical and non-clinical champion.
   • Are they able to implement changes?
   • Is there someone at the system level with whom you can partner? For example, a Disability Coordinator or your organization’s ADA Coordinator is often already responsible for monitoring accessibility-related complaints and compliance.
5. Establish common goals for team.
   • Ensure that it fits within organizational goals and regulatory deadlines.
   • Use SMART Goals (Specific, Measurable, Attainable, Realistic, and Time-bound).

Materials and Resources

• Appendix 0.4: Disability Organizations↗
• Appendix 0.6: Project Planning↗
• Appendix 6.1: Physical Structures Implementation and Project Teams
• Appendix 6.3: Physical Structures Implementation Planning Worksheet
• Appendix 6.11: Physical Structures Barriers and Strategies

*Appendices 0.4 and 0.6 can be accessed in the General Resources chapter.

Using Appendix 6.2: Physical Structures Needs Assessment, evaluate the current state of accessibility at your organization’s buildings, structures, and facilities. Complete a comprehensive accessibility survey of your site(s).

Actions and Tasks

1. Locate existing barrier removal plans, deferred maintenance lists, accessibility complaints, grievances, patient experience surveys, or legal actions taken against your organization related to the construction, design, or navigation of a space. This will help you understand your organization’s priorities and motivations.
2. Identify if there are any non-accessibility projects in the planning stages across your organization. There may be opportunities to leverage them for accessibility work and minimize disruptions to clinical operations.

3. Review your organization’s capital project request policies. Identify internal project proposal deadlines and create timelines to prepare for budget requests when needed.

4. Use the ADA Checklist for Existing Facilities↗ to identify accessibility barriers at each location. Before starting the survey, consider:

• • Will you hire an external firm or surveyor to evaluate your facility? If so, what is the budget?
  • If conducting the survey internally:
    • Who/what team(s) will be responsible?
    • How many hours will be dedicated to conducting the survey(s)?
    • What training or information is needed to conduct the survey accurately?
  • What supplies will you need?
  • How many of each feature included on the checklist, i.e., doors, parking spaces, bathrooms, exam rooms, waiting rooms, etc. are in your facility? How many must be accessible?
  • What is your data management plan? Is there an existing template you can adapt to track recorded measurements and other data? See Appendix 6.4: Physical Structures Survey Data Template.
  • What reports will you generate with the survey results, such as a Barrier Removal Plan (see Appendix 6.9: Physical Structures Barrier Removal Guidance)?

5. Engage with other healthcare organizations to understand their approaches to assessing built environments and making them accessible, including what is and isn’t working for them. Consider joining the Disability Equity Collaborative’s Leaders workgroup to create a peer network.

Materials and Resources

• Appendix 6.2: Physical Structures Needs Assessment
• Appendix 6.4: Physical Structures Survey Data Template
• Appendix 6.9: Physical Structures Barrier Removal Guidance
• Appendix 6.13: Physical Structures Training Resources
• ADA Checklist for Existing Facilities↗
• Disability Equity Collaborative’s Leaders workgroup↗

Determine what accessibility upgrades your organization will pursue, how and when they will be completed, and who will be responsible. Use Appendix 6.3: Physical Structures Implementation Planning Worksheet to specify site or clinic goals, strategies, timelines, milestones, and measures for implementation.

NOTE: Constructing or renovating a healthcare facility is a highly regulated process. It is beyond the scope of this chapter to address non-accessibility-related aspects of healthcare construction. For a breakdown of actions and tasks to complete in preparation for new construction, remodel, or renovation, see Appendix 6.8: Physical Structures Project Best Practices and Timeline.

Actions and Tasks

1. Use your completed accessibility survey to determine what projects your clinic or organization will pursue and where. Identify:
   • Modifications internal facilities management or maintenance staff can manage, including “readily achievable barrier removal,” such as lowering mirrors, replacing doorknobs, reconfiguring reach ranges for bathroom fixtures, etc.;
   • Structural upgrades or renovations your organization will pursue;
   • Accessibility features to purchase and install;
   • Changes that are “technically infeasible” due to structural or space constraints

2. Consider exposure to legal action for non-compliance. This will help you identify the barriers most likely to disrupt patients’ access to care and result in a lawsuit and therefore determine which remodels to prioritize.
3. Identify the scope of the project(s). Are you pursuing multiple projects organization wide, or focusing on upgrades in a single clinic?
4. Identify your project(s) team. Determine whether you need to create/provide training or resources to educate project planning team members on accessibility in the healthcare context, or include members on the project team that already have accessibility expertise.
   • Peer to peer information can be more persuasive. For example, architects are more likely to listen to other architects with accessibility-specific knowledge.
5. Plan how construction contracts, accessibility features, and other suppliers will be purchased/paid for, including which budgets will fund them.
6. In consultation with your project and/or implementation team, develop a project timeline. Identify a target opening/reopening date for the facility, if applicable.
7. For existing facilities, work with clinic staff to understand how clinical operations will be disrupted by the project(s). Develop solutions and contingency plans.
8. For existing facilities, work with facility leadership and/or finance departments to understand the indirect financial impacts of the project. How will you address concerns about lost revenue during the construction period?
   • Will the unit have to pause operations, or can the project be completed with minimal disruptions to clinical care?
   • How will you create and inform staff/patients about alternative accessible pathways during construction?
   • How will dust, debris, and other irritants from construction be managed in the clinical environment?
   • If clinical operations must be paused:
     • Will clinicians provide care at another location?
     • Will appointments be rescheduled?
     • Will patients be referred to another facility?

9. Be prepared for the project’s scope to expand. Consider the implications for the project’s budget and the project area itself.
   • For example, if your original plan is to install grab bars in a toilet room, you may discover the existing room is too small and must instead be taken down to the studs and reconfigured.
10. Following decisions made on processes, funding, and roles, revisit the composition of the implementation team. Determine if additional individuals from departments or units that will be involved in any aspect of the project should be included.

Materials and Resources

• Appendix 0.6: Project Planning↗
• Appendix 6.1: Physical Structures Implementation and Project Teams
• Appendix 6.5: Physical Structures Costs and Funding
• Appendix 6.6: Physical Structures Upgrade List
• Appendix 6.7: Physical Structures Rented/Leased Spaces Guidance
• Appendix 6.8: Physical Structures Project Best Practices and Timeline
• Appendix 6.9: Physical Structures Barrier Removal Guidance
• Appendix 6.10: Physical Structures New Construction Guidance

*Appendix 0.6 can be accessed in the General Resources chapter.

Begin the construction/installation phase of the project. Consider the following actions to ensure staff, patients, and your organization’s systems are prepared for to resume care delivery following project completion.

Actions and Tasks

1. Identify who will design clinic workflows for a new facility, or redesign clinic workflows for the remodeled space. Will this be internal staff or an external consultant?
2. For barriers that are “technically infeasible” to remove, determine an alternative method to safely deliver care. See Appendix 6.6: Physical Structures Upgrade List.
3. Determine who will provide consultation to assist with training for providers and staff on how to use accessibility features/navigate the newly accessible facility.
   • This person (or people) will offer expert guidance, feedback, and problem-solving to a site longitudinally.
   • This can be a practice facilitator or similar role.
4. Identify or create resources and trainings on how to use accessibility features/navigate the newly accessible facility.
   • Determine how trainings may differ depending on staff roles.
   • Determine frequency of training/re-training (e.g., one time, annual, etc.)
5. Identify or develop tools and reminders to encourage staff to maintain the accessible layout of a room.
   • Pictures and diagrams can be helpful. For example, post photos or diagrams in an exam room of its intended layout so that staff can maintain accessibility.
6. Decide how accessibility features will be maintained in the clinic or unit. Aim to integrate the process into existing clinic and system-level workflows when possible. Consider:
   • Who in the facility will be responsible for observing and tracking repair/replacement needs?
   • What is the process for clinic staff to request a repair/replacement?
   • What budgets will fund repairs/replacements?
7. Before the facility opens/reopens, conduct a final third-party accessibility survey of the space. Document and make any necessary changes.

8. Identify or develop patient-facing education materials to disseminate information on available accessibility features, rooms, etc.
9. Determine how success will be defined for building more accessible physical structures and environments.
   • Specify how you will monitor or assess patient experience, complaints, and outcomes.
   • Develop an evaluation plan to reflect your definition of success.

Materials and Resources

• Appendix 6.3: Physical Structures Implementation Planning Worksheet
• Appendix 6.6: Physical Structures Upgrade List
• Appendix 6.11: Physical Structures Barriers & Strategies
• Appendix 6.12: Physical Structures Monitoring Progress and Adaptations
• Appendix 6.13: Physical Structures Training Resources
• ADA Checklists for Existing Facilities: Frequently Asked Questions↗

Open your new, reopen your existing, or resume normal operations at your facility. Monitor and regularly evaluate patient experience and any changes to outcomes related to the accessibility of the space.

Actions and Tasks

1. Conduct patient surveys to collect data on patients’ experience in newly-accessible spaces.
2. Track any changes to patient outcomes (i.e., rates of missed appointments) or patient complaints. Communicate those to responsible individuals (e.g., clinic leadership, system leadership, staff working in these spaces) and the implementation team.
3. Make and document all needed adaptations.
4. Recognize high performing clinics or sites to celebrate improved patient navigability, experience, or outcomes.

Materials and Resources

• Appendix 6.11: Physical Structures Barriers & Strategies
• Appendix 6.12: Physical Structures Monitoring Progress and Adaptations
• ADA Checklists for Existing Facilities: Frequently Asked Questions↗