Values Engineering: The Ethics of Design in Community Health Centers

Architecture, like ethics, concerns actual rather than ideal choices. William James's remarks on ethics, at a meeting of the Yale Philosophical Club in 1890, could apply equally well to the built environment:

The actual possible in this world is vastly narrower than all that is demanded; and there is always a pinch between the ideal and the actual which can only be got through by leaving part of the ideal behind. There is hardly a good which we can imagine except as competing for the possession of the same bit of space and time with some other imagined good.¹

Health care facilities are spaces in which certain imagined goods—the care of the sick, the treatment or prevention of disease—meet the actual possible of resource allocation. They are complex institutions, socially and with respect to their physical features: health care design is a highly specialized area of architecture. Hospitals are one type of health care facility in which ethical goals, such as error prevention and better coordination of care, can be supported by the built environment through the development and application of evidence-based design. Architecture and design also support ethical goals in other types of health care facilities, including the nonprofit, federally funded community health centers known as federally qualified health centers (FQHCs), which are organized around the ethical goal of improving access to primary care for medically underserved populations.

There are more than 1,100 FQHCs nationwide. In 2009, 18.8 million patients received primary medical care, dental care, and behavioral health services at them. The centers serve as a safety net for the uninsured, as well as for people insured by Medicaid and the State Children's Health Insurance Program, migrant workers, public housing residents, and the homeless. However, FQHCs accept patients regardless of payer or income, and from June 2008 to June 2009, the number of visits to FQHCs grew by 14 percent due to the economic downturn.² At a time of record long-term unemployment and the loss of employment-related health insurance, FQHCs are serving as a safety net for a new population.

FQHCs are undergoing their largest capital expansion since 2002 as the result of $2 billion in economic stimulus funding and an additional $11 billion from the Patient Protection and Affordable Care Act. The expansion includes construction projects and supports collaborations between FQHCs and hospitals to recruit and train primary care physicians to work in community settings. Analysts predict that FQHCs will fill gaps in health reform by serving patients who cannot afford to buy insurance or cannot obtain it even on the health insurance exchanges (as is the case for undocumented patients) and because they are already established in rural areas where primary care options are limited.

FQHCs offer opportunities to explore the role of architecture, planning, and design in efforts to realize complex and competing ethical goals ranging from equality to safety, effectiveness, and efficiency. Health centers, like hospitals, are accountable for promoting patient safety through the built environment. Their designers draw on evidence concerning how to facilitate hygiene, use task lighting, or use signage to (for example) reduce the risk of nosocomial infection or medication error and help patients and families navigate a facility.

FQHCs have special design challenges related to their mandates. Because FQHCs are centers for health education, their design must include dedicated spaces for education and outreach. Because they aim to coordinate a patient's health needs, architects must accommodate services, such as dental care, that draw patients to a center and provide access to other services. FQHC architects, like hospital architects, follow multiple sets of stringent guidelines and standards, ever mindful of their client's mandate to be genuinely community-centered and to be responsive to the health needs and cultural preferences of specific populations. An FQHC's interiors may incorporate cultural motifs or artwork representing a population they serve. They aim to be welcoming places. "Institutional" colors are often avoided in favor of a warmer palette. A waiting room wall in one center is decorated with child-size handprints (made by the seven...