Evidence-based Design - Background

Background

Many recent studies have examined how physical environment can influence well-being, promote healing, relieve patient pain and stress, and also reduce medical errors, infections and falls. Many hospitals are adopting elements of evidence-based design in new construction, expansion or re-modeling.

It is a process used by architects, interior designers, facility managers, and others in the planning, design, and construction of commercial buildings. An evidence-based designer, together with an informed client, makes decisions based on the best information available from research, from project evaluations, and from evidence gathered from the operations of the client. Critical thinking is required to develop an appropriate solution to the design problem. The pool of information will rarely offer a precise fit with a client's unique situation. Therefore, research that is specific to the project's objectives is almost always required. In the final analysis, an evidence-based design should result in demonstrated improvements in the organization's outcomes, economic performance, productivity, customer satisfaction, and cultural measures.

The process works well in the healthcare field but has many relations with complementary fields and some fallouts in distant fields. This approach appeals to many who are directly and indirectly involved in this area of research. The positive effect is shown from the patients and families, who have higher-quality stays; physicians, who practice based on medical evidence and business-minded administrators, who prove this would reduce costs and improve organizational effectiveness.

However, it is applicable to many types of commercial building projects, but is uniquely suited to healthcare because of the unusually high stakes and the financial and clinical outcomes that can be impacted by the built environment. The building itself can help to reduce the stress experienced by patients, their families, and the teams caring for them. The healthcare environment is a work environment for the staff, a healing environment for patients and families, a business environment for the provision of healthcare, and a cultural environment for the organization to fulfill its mission and vision.

Research relevant to healthcare design can come from many areas:

• Environmental psychologists focus on stress reduction, which includes:
  1. social support (patients, family, staff);
  2. control (privacy, choices, escape);
  3. positive distractions (artwork, music, entertainment);
  4. influence of nature (plants, flowers, water, wildlife, nature sounds).
• Clinicians focus on medical and scientific literature, which includes:
  1. treatment modalities (models of care, technology);
  2. quality & safety (infections, errors, falls);
  3. exercise (exertion, rehabilitation).
• Administration refers to management literature:
  1. financial performance (margin, cost per patient day, nursing hours);
  2. operational efficiency (transfers, utilization, resource conservation);
  3. satisfaction (patient, staff, physician, turnover).
• Evidence-Based Metrics includes Research Tools and Methods for Practitioners:
  1. Work Measurement PDA (Time Study RN/MD);
  2. Design for Efficiency (Layout-iQ);
  3. Patient and Resource Workflow (Rapid Modeling).

Approximately 1,200 credible studies with specific environmental relevance have been identified by The Center for Health Design in these areas, and many more applicable research citations are in other branches of the literature.

Hospital designers' and administrators' main aim is to create a healing space. It could be defined as a space that reduces stress, helps health and healing, and improves patient and staff safety.

The notion of a healing space goes back to ancient Greece. People who were ill looked toward temples in the hope of having dreams where the god would reveal cures. Later, in 1860, Florence Nightingale fixed ventilation and fresh air as “the very first canon of nursing,” and underlined the importance of quiet, proper lighting, warmth, and clean water. Nightingale learned statistics and applied it to nursing, writing the "Diagram of the causes of mortality in the army in the East". These statistical studies led to advances in sanitation, even though the germ theory of disease was not yet fully accepted. Those statistical studies could be said to be one of the early advances in evidence-based medicine. Then, a pioneering study conducted by Roger Ulrich in 1984 found that surgery patients with a view of nature suffered fewer complications, used less pain medication, and were discharged sooner than those with a brick wall view. In addition, studies exist about the psychological effects of lighting, carpeting, and noise on critical-care patients.

Currently, there is evidence that links the physical environment with the improvement of patients and staff safety, wellness and satisfaction.

EBD continues several research and building practices that were developed in the 1960s. For example, in the 1970s in the USA and UK, architectural researchers studied the impact of hospital layout on staff effectiveness (Clipson & Johnson 1987; Clipson & Wehrer 1973; Medical Architecture Research Unit, 1971–1977) and social scientists studied issues such as guidance and wayfinding (Carpman & Grant 1993). Besides, architectural researchers have explored how Post-Occupancy Evaluation (POE) to provide useful advice to improve design and building quality (Baird, Gray, Isaacs, Kernohan, & McIndoe, 1996; Zimring, 2002).

Today, The Center for Health Design is focused on EBD practices, their use and application to each step of the design process. More than 600 credible studies with specific environmental design relevance have been identified.