Architecture: Two local clinics take a fresh approach to emergency rooms

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Mark Lamster
Architecture Critic
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Published: 26 April 2014 09:38 AM
Updated: 26 April 2014 05:39 PM

ALLEN — On any list of undesirable places to visit, a hospital emergency room sits near the top. You’re there either because you’re in pain or because someone you care about is in pain, and odds are good that you’re going to be there for a while, that it’s going to be expensive, and that the space itself — bleak fluorescent lighting, stained linoleum floors, shabby furniture — isn’t going to make you feel any better.

Yet we all end up in these dismal spaces. According to the American College of Emergency Physicians, 40 percent of Americans visit emergency rooms every year. These facilities received a collective national grade of D+ in the organization’s annual report card evaluating performance. Texas ranked a dispiriting 38th among states, with grades of F in quality/patient safety and access to care.

An alternative to this grim state of affairs, with broad implications for emergency medical care across the nation, may be found along an unremarkable stretch of parkway in Allen. Here, standing out in the sprawl of cookie-cutter housing developments and strip-mall chain stores, is an object that seems delivered from the realm of science fiction, a mechanical insect of folded zinc planes, jutting angles and perforated screens.

This invader is a free-standing emergency room and urgent-care center, the second of two owned and operated by local doctors who had grown frustrated by the daily indignities of hospital-based emergency care. “There are a lot of entrepreneurial physicians who feel they can do it in a better way,” says Kirk Mahon, one of the three founding partners of Legacy ER.

The group’s first clinic, somewhat more restrained architecturally, opened in nearby Frisco in 2008. Its success encouraged the partners to build the more ambitious facility in Allen, which received its first patients in February.

Both were designed by Yen Ong, a partner in the Dallas-based 5G Studio Collaborative, an upstart 30-person architectural firm that flashed to local prominence with the building-as-billboard Dallas Omni Hotel. Like its physician clients, 5G was born of a frustration with the standards of professional practice; it was formed by refugees from the Beck Group, a stalwart of Dallas corporate architecture.

A growing market

While atypical in outward appearance, the Legacy ER clinics represent a rapidly growing segment of the health care market: the independent free-standing emergency care center. Texas is at the forefront of this development, in large measure due to state laws that force insurers to pay emergency claims promptly. According to Joe Ybarra, president of the Texas Association of Freestanding Emergency Centers, there are more than 90 such clinics operating in Texas, far more than in any other state.

The proliferation has engendered a host of concerns among medical professionals. Because they are for-profit endeavors and not recognized for reimbursement by Medicaid and Medicare, they are almost always located in affluent areas. That means the centers do little to expand access to care where it is most needed. An American College of Emergency Physicians white paper expressed fears that such centers would skim off well-paying patients, leaving already-pressed hospitals with a “disproportionate share of low-pay or no-pay patients.” They are permitted to charge hefty facility fees, and opaque ownership — some are physician-owned and others are financed by private investors and hospitals — can lead to confusion among consumers, who often come to them in desperation.

Dallas’ Parkland Hospital, which will debut a new trauma center in 2015 as part of its ruthlessly modern multibillion-dollar expansion, has no plans to open its own free-standing emergency centers.

Architectural cure

For all of the concerns raised by their emergence, the two Legacy ER facilities stand out from their generic, doc-in-a-box peers as models of how architecture can improve the delivery of medical care. Both were conceived using the principles of evidence-based design, a methodology of growing prominence in the health care field in which empirical research is applied throughout the design process to enhance efficiency, safety and patient experience.

The methodology can increase costs in the short term but yield long-term benefits, both human and financial. For example, the plumbing in exam rooms, ordinarily installed back-to-back in adjoining rooms to save money, is instead aligned in parallel, so that patients are always approached from the same side, the left, which studies show reduces mistakes born of constant reorientation.

Ong embraced this philosophy in the wake of a family health scare of his own: the premature arrival of a child, which brought him into the dank corridors of a large Dallas hospital. “Here I was in an emergency situation, my second son’s life is at stake, and there’s nothing in this hospital that comforts me or my wife,” says Ong. “There’s no environmental or architectural cue that lets us know we are not the only people in the world experiencing this.”

At Legacy ER’s Allen clinic, this signal is delivered in no uncertain terms by the origami folds of its eye-catching front facade, which is set back judiciously behind a landscaped parking area.

“Modern was part of the ticket,” says Jay Woody, another of Legacy ER’s founding partners. “That’s something we wanted. If you’re having a heart attack, you want to have people that look like they have the latest technology. If you see a building that’s dingy and dull, you wonder if their medical knowledge is up to date.”

That modern aesthetic met with considerable resistance during the planning of the group’s first clinic in Frisco. In part that was because 5G had been commissioned through a turnkey developer that imposed its own requirements. (For the Allen project, the physician partners contracted directly with 5G.)

The design, with a shallow canopy projecting over a glass and beige brick facade, ran into roadblocks with the Frisco planning department. It delayed approval for months on the grounds that the design was not contextual with neighboring development, though the only significant nearby buildings were a preschool and a chain drugstore. After the project won an award from a health-care design publication, the city gave its blessing.

Humane design

Within, the clinics demonstrate that modern design, so often derided as clinically sterile, can be gracious and humane — even in clinically sterile environments. “I had surgery one time, and I remember going onto the steel table, and that was very cold and discombobulating,” says Mahon. “We tried to take that aspect out of it.”

That is accomplished, above all, by suffusing spaces with natural light and views to the outdoors, to counter the perception of being trapped within a frightening mechanical universe of blipping machines and scary equipment.

“It’s real minimal and clean-looking,” says Amy Hargrove, a school nurse from Allen who used the Allen facility when she fell ill with the flu. “It’s intriguing.”

Patients enter into limpid, glass-walled reception and waiting areas with seating designed by 5G. Exam rooms are windowed with either fritted glass or the windows are placed high enough to ensure privacy. Corridors are sky-lit and terminate, whenever possible, with windows framing pleasant views. In Frisco, lime green accent walls give a visual boost to the proceedings; in the triage room, a photograph of trees in Reverchon Park, screened onto a resin panel, introduces the the natural world into what might otherwise be a claustrophobic space. “It’s not a scary emergency room. It invites you in and makes you feel comfortable at a time you’re in a bad situation,” says Woody.

In plan, the facilities are simple rectangles, their clinical areas divided longitudinally to accommodate Legacy ER’s dual program of emergency medicine (for which there are more stringent state regulations) and less critical urgent care. At the Allen clinic, this divide is visually reinforced by the floor surface; the emergency care section is decked with a seamless gray sheet-rubber while the urgent care areas are surfaced with polished concrete flecked with recycled mirrors.

Compact footprints and creative space planning, hallmarks of evidence-based design, are a response to the imperative for efficiency. “In medical practice, a few seconds count a lot,” says Ong. Panoptic nursing stations act as the brains of the clinical zones, with shifting counter heights designed so practitioners can interact with patients while sitting or standing. The facilities are designed to handle more than 100 patients a day, covered by a rotating staff of about 15.

The facilities provide ample space for staff to unwind. In Allen, the partners can remove themselves to a second-story conference room tucked under the folded zinc roof planes, reached by a steel stair and catwalk painted in sea blue. A bedroom and bathroom are provided for physicians on overnight call.

Whether the emergence of free-standing emergency care centers is a malignant or benign development remains an open question. But the essential elements of these two forward-thinking facilities are clearly scalable. Architects, physicians and administrators can look to them and be expected to improve the environments created for emergency care. Residents of cities and suburbs alike should demand that municipalities welcome innovative design, not stifle it in favor of short-term economy and bogus, deadening contextualism.

Mark Lamster is the architecture critic of The Dallas Morning News and a professor at the University of Texas at Arlington School of Architecture.

On Twitter:  @marklamster