Architecture

“Design a state-of-the-art faculty dental practice with the ambience of a Ritz-Carlton Hotel”-that was the dictate of Harold Slavkin, DDS, the new dean of the University of Southern California School of Dentistry. Lured from his position as director of the National Institute of Dental and Craniofacial Research (NIDCR), one of the 19 National Institutes of Health, Dr. Slavkin returned to California with the dream of making USC one of the top dental schools in the nation. One piece of this grand design was recruiting and retaining top faculty by providing a private-practice environment offering high-quality care focused on restorative and cosmetic dentistry.

Another goal was to kick off an AEGD (Advanced Education in General Dentistry) program that would give recent graduates experience working in an optimal private-practice model, using a treatment coordinator and working collaboratively with a hygienist. Faculty would supervise residents.

A functional aspect of the program dictated that the facility be able to handle the volume of all incoming student dental checkups as part of the student health program, and also to serve university faculty and their families. Moreover, a “good neighbor” policy described in the facility’s mission statement was to create an “economic engine” for the community by training dental assistants, business office personnel, and lab techs, thus offering local residents an opportunity for better jobs.

The location selected for the facility was a 9,800-sq.-ft. space in a university-owned retail mall directly across the street from the campus in downtown Los Angeles. This provided enhanced convenience for patients, including opportunities for the facility to offer them extended hours.

Planning Challenges

As planning progressed, it became clear that 24 treatment rooms would be required to fulfill the projections of the business plan, but this was impossible within the space available using conventional stud and drywall partitions. Modular casework, used as a common wall, would make the 24 treatment rooms possible, but then privacy and aesthetics would become concerns. Keeping in mind the goal of creating an optimal experience for patients, acoustic and visual privacy were deemed essential.

Another consideration was whether the A-dec modular casework could be integrated into the design of the headwall (known as the “12 o’clock wall” in dental design) and sidewalls in such a manner as to appear custom-made, without sacrificing the “Ritz-Carlton” ambience. The solution was to create a drywall partition on the corridor side of the headwall, with frosted glass doors opening into the rear of the A-dec cabinet for passing clean trays and tubs of sterilized instruments and materials into the room (Figure 1). An acoustical full-height wall treatment at the toe end of the dental chair met the sidewall casework to provide auditory privacy.

The casework on either side of the dental chair is 88″ high and, where it meets the headwall soffit, creates the appearance of a private room. The air space above the casework has obvious advantages in terms of ventilation, and it also permits light to flow from one treatment room to another, creating a more spacious feeling (Figures 2 and 3).

Flexibility was another key objective of the design. The plan was to provide two treatment rooms (also called “operatories”) per doctor. Each bay would accommodate four practition-ers, plus provide an additional “floater” room to be used by a hygienist or by any of the doctors, as necessary. The two totally private treatment rooms in the center core are for campus VIPs or patients undergoing lengthy cosmetic dentistry procedures. The four other treatment rooms in the central core are for hygiene procedures and open onto a garden with boulders and a Japanese granite fountain (Figures 4 and 6).

All treatment rooms are the same size and equipped alike, making them highly flexible and interchangeable in terms of scheduling. The AEGD program will be run in the treatment rooms on the right side of the space plan (Figure 5), because these are close to the seminar room (not shown in plan) and to staff who are associated with this training. Patients have the option of entering from a separate reception area (not shown in plan), enabling the AEGD clinic to function independently, if desired, while faculty are seeing patients in the rooms to the left of the center core. This enables 50 to 60 faculty to be accommodated, each working one day per week. On days when the AEGD program is not operating, faculty may use all treatment rooms.

Patient flow and other operational features are set up as follows:

• A greeter funnels patients to each waiting room. Computers on either side of the fountain in the greeter area allow patients to fill out or update medical histories (Figure 7).

• Patients proceed to the check-in area and, if they are new patients, may have x-rays taken in a central location (#9 on space plan), be-fore proceeding to a treatment room. The central x-ray functions well for high-volume screening of students before their initial evaluations.

• After the initial evaluation and development of a treatment plan, the patient is offered the option of continuing with a resident or faculty member. The treatment coordinator discusses financial arrangements, and a schedule of appointments is developed.

• Check-in and checkout functions have been separated to enable the patient to exit without having to backtrack through the waiting rooms (Figure 8).

• Doctors have several ways of entering and exiting the facility without running into patients in the waiting room. Dental residents are able to travel quickly between the AEGD area and classes across the street on campus.

• The rear service entrance accommodates lab deliveries, linen service, hazardous materials pickup, and delivery of supplies. This is also the staff entry closest to parking and enables staff to pick up a lab coat and place personal belongings in lockers (#15 on space plan).

• The sterilization process is central to all three pods, as are faculty dictation and the faculty-shared office. Out of view on the space plan are a seminar room with attached kitchen/break room, production lab, and administrative offices. Billing is handled off-site.

Up-to-Date Technology

Some of the more high-tech features of the new facility include the ability to book an initial appointment on the Internet; totally paperless records (medical records can be transferred digitally from student health to the patient’s dental record); and paperless electronic connectivity among all aspects of practice management and clinical care, with computers located at all workstations and on the 12 o’clock wall in the treatment rooms. The latter feature enables seamless transfer of information, starting with scheduling and ending with electronic processing of insurance claims.

All treatment rooms have intraoral cameras, enabling oral images to be displayed on a monitor observable by both the doctor and patient. Extraoral cameras (imaging area, #9 on plan) are used with cosmetic imaging software to show how a patient’s face will change after dental treatment. Operating microscopes enable dentists to work while sitting up straight and looking forward through the microscope, rather than bending over the patient. This allows the dentist and hygienists to see better and work at a more ergonomic advantage.

Also featured are intraoral x-ray heads that swing between every two treatment rooms. The panoramic x-ray is centralized. The digital radiography used exposes patients to far less radiation and permits the practitioner to see the digital image instantly, manipulate it, and electronically transfer it to the patient’s record. Dual monitors allow the patient to see what the doctor is seeing (Figures 2 and 3). This helps dentists to discuss cases with patients more effectively.

Treatment rooms are ambidextrous; the patient monitor is on an arm that can swing from the right to the left side of the chair and vice versa, as can the doctor’s instruments. The assistant’s cart has a swing-away bracket to transfer the hoses to the other side of the cart when staff is assisting from the right side of the chair.

Another high-tech feature is that sterilization is performed using sterilization cassettes. Instruments are delivered to the treatment field from the rear, keeping handpieces out of patients’ view when they enter the room.

Communications technology includes a digital communication system with other stations at the reception desks, enabling the dentist or assistant to relay or receive messages in text (thus, with no auditory disturbance to the patient) via a panel mounted at the headwall. There are large, flat-panel monitors in both waiting areas, enabling educational programming to be presented to patients on dental procedures and services.

Creating a Nurturing Environment

It is known that a soothing, comfortable environment reduces patient anxiety. In this case, the facility’s color palette (beige, amethyst, and buttercup yellow) is expressed in materials that emphasize texture. This starts with the carpet, with its unique pattern that appears to be sculpted. Many walls have fabric-wrapped acoustic panels. A custom art-glass sculpture by Jay Curtis in the greeter area is framed by maple millwork (Figure 7). Floors of treatment rooms are maple wood-grained sheet vinyl. Deeply embossed ceramic tile complements the wall fountain in one operatory corridor (Figure 9).

Positive distractions include three fountains, one of which is part of an interior garden in the hygiene corridor (Figures 4 and 6). Theatrical lighting recessed into the cavity of the ceiling (Figure 4) creates dramatic “stepping stones” on the carpet. Throughout, lighting is indirect and without glare, whether on top of the canopies in the corridors (Figures 1 and 9), in the large pendant fixtures under the perforated-aluminum vaulted ceilings, or in the reception offices and treatment rooms. Acoustic tile with ultrahigh NRC (noise reduction coefficient) has been successful in creating a quiet environment, even when all treatment rooms are in use.

Patients have a stress-reducing connection to nature, despite windowless operatories, by way of backlit film images of tropical islands positioned overhead (Figures 2 and 3).

Emerging Technologies

Recent advances in dental technology to enhance diagnostic capabilities and improve treatment are revolutionary compared to what was available only five years ago. The USC Oral Health Center is positioned to become a beta-testing site for emerging technologies. It will always be in touch with the “soft side” of care, however, never losing sight of the importance of the treatment environment to patients and staff. HD

Jain Malkin is president of Jain Malkin Inc., San Diego.

For further information, phone (858) 454-3377 or visit http://www.jainmalkin.com.

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Project Summary

Client: University of Southern California School of Dentistry

Design Architect: Jain Malkin Inc. (JMI)

Programming and Space Planning: Jain Malkin Inc.

JMI Team: Jain Malkin; Joost Bende, AIA; Michele Woodard; Chris Shinall

Architect of Record: The Neiman Group

Lighting Design: Jain Malkin Inc.

Equipment Planning: Lee Palmer, Burkhart Dental

Contractor: Sanders Construction

USC Project Manager: Steve Lohr

Photography: Steve McClelland

Completed: January 2003

Total Building Area (gross sq. ft.): 9,800

Total Cost (excluding land): $1,615,000

Cost per Square Foot: $155 (Note: Total cost includes considerable repair of building shell.)

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Toward 21st-Century Dentistry

Interview with Harold Slavkin, DDS, Dean, University of Southern California School of Dentistry

How did your vision for this new dental-practice unit come about?

Dr. Slavkin: When I was director of the National Institute of Dental and Craniofacial Research from 1995 to 2000, I had the opportunity to visit all of the dental schools in North America, observe a lot of best practices, and see what it takes to earn the perception of a Mayo-Clinic-like facility. When I was recruited to come to USC, I visited the existing intramural faculty practice and asked, “Does this look like the front porch of a 21st-century school of dentistry? Does it have the technology to support administrative management? Does it use the best practices of the time?” The consensus was that we could do a lot better. Working with Jain Malkin, after the architectural bidding process, we also asked what we could do to make this place an incredible attraction in recruiting world-class faculty, to have it serve as a model for the highest level of care, and to make it accessible not only to faculty and students, but to the community around us. Jain took a very ordinary space and made it into an incredibly attractive environment.

What was the process involved in realizing this vision?

Dr. Slavkin: Aside from a standing committee of 10 that met weekly to evaluate ideas, we had literally 100 people giving us input-our very active board, information technology consultants, dental supply companies, management consultants, people from the community, and more. I was at the end of the line with some veto power, but I thought the ideas that emerged from this were fabulous.

How does the design of the operatories differ from that of the “standard” dental practice?

Dr. Slavkin: There is more room, and there are more informatics, so that students can observe and learn. Even though the operatories don’t have doors, because of the handling of the design and acoustics, they give the feeling of privacy.

What were some of the principal difficulties involved in achieving this?

Dr. Slavkin: Anytime you look at new technology, the most difficult thing in the world is to have each student and faculty member internalize a desire to upgrade his or her skill sets. For example, we have microscopes in the operatories, digital radiography, computer touch screens-many of us were never trained to use any of this, but in today’s environment, you have to. There was resistance from some, but on the other hand we have faculty members in their 50s and 60s who are thrilled about learning these new skills-they’re like kids!

There is also a paradigm change in dental practice going on here. Most of us were trained to diagnose quickly and spend all of our time on treatment. Now we take a very careful, detailed approach to health promotion, risk assessment, disease prevention, diagnostics, treatment and therapeutics, and outcomes assessments. The 21st century is about health outcomes, about learning from the treatment you’ve provided. This should be a core value at the university level. Because of the way this facility is designed, we are working toward broadening the concept of oral health professional school education.

Healthcare Design 2003 May;3(2):68-72