The New Evidence-based Designers

D. Kirk Hamilton, MSOD, FAIA, FACHA

With serious consequences at stake, many healthcare practitioners are embracing the use of credible research to design better buildings.

The Center for Health Design's mission is to improve the quality of healthcare and promote life-enhancing healthcare environments by demonstrating the value of evidence-based design. For the past 15 years, the center's founders have been actively engaged in doing this through education, research and dissemination of information. We are happy to report that "evidence-based design" seems to have finally made it into the healthcare vernacular. In fact, clients are beginning to ask about it in their requests for qualifications.

This is all great news, but it does cause us to pause and ask, "What is evidence-based design, and what does it take to be an evidence-based healthcare designer?"

Evidence-based design is the natural parallel and analog to evidence-based medicine. Evidence-based healthcare designers make critical decisions, together with informed clients, on the basis of the best available information from credible research and the evaluation of completed projects. This is a method applicable to many types of projects, but in healthcare it is a powerful means to convince decision-makers to invest the time and money to build it right—and realize strategic business advantages as a result.

Research relevant to healthcare design can come from many areas:

Environmental psychologists focus on stress reduction:
1. Social Support
(patients, family, staff)
2. Control
(privacy, choices, escape)
3. Positive Distractions
(artwork, music)
4. Influence of Nature
(plants, flowers, water, wildlife, nature sounds)

Clinicians focus on medical and scientific literature:
1. Treatment Modalities
(models of care, technology)
2. Quality and 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)

Numerous credible studies with specific environmental relevance have been identified in these areas, and many more applicable research citations are in other branches of the literature. The Robert Wood Johnson Foundation has awarded The Center for Health Design a grant to compile currently available relevant evidence-based healthcare design research, including material from three years of our Pebble Project research initiative. We expect to publish a report in the spring.

Most of us doing healthcare design have developed a strong functional perspective in our work. The knowledge that important design concepts have been tested and there is data to inform our designs should be comforting. With serious consequences at stake—sickness and health, even life or death—most of us welcome the emergence of solid foundations on which to base important design decisions. Some might be concerned that evidence-based design could limit their creativity or freedom of choice. Yet, research encourages us to test new and interesting ideas; and it is continually evolving to challenge us to design better buildings. I propose that there are four levels of evidence-based design practitioners:

Level one Practitioners:
These architects and designers make a careful effort to design based on the available evidence. They try to stay current with literature in the field by following the environmental and healthcare research that relates to the physical setting. Level One practitioners interpret the meaning of the evidence as it relates to their projects, and make judgments as to the best design for that specific circumstance. They advance the state-of-the-art by learning from others and developing additional examples, while delivering improvement for their clients.

Level Two Practitioners:
Evidence-based practitioners at Level Two take another important step. They hypothesize the expected outcomes of design interventions and measure the results. This means predicting the intended positive outcome associated with a design decision, and committing time and resources to measure whether or not the results were achieved. This level of attention makes design less subjective, and challenges them to design with accountability. They must understand the research, interpret its implications, and be able to build a chain of logic to connect the design decision to a measurable outcome.

Level three Practitioners:
In addition to following the literature, hypothesizing the outcome of their interventions, and measuring the results, Level Three practitioners report those results in the public arena. Publishing in the trade press or speaking about the results at conferences makes an important contribution to the field and advances the state-of-the-art by making information available to others. It also subjects the methods and results to the scrutiny of others who may or may not agree with the findings. Level Three practitioners subject their work to independent third-party post occupancy evaluation.

Level four Practitioners:
This architect or designer performs the same tasks as those in the other levels—following the literature, hypothesizing the outcomes of design interventions, measuring the results and reporting in the public arena. Level Four practitioners go to the next step by subjecting their work to peer review, as when publishing in journals that require review by qualified experts. They may collaborate with clinicians or social scientists in academic settings. They are working directly in the field, designing and building operating healthcare facilities, but also subjecting their work to the rigor of critical review and formally advancing the useful evidence in the field.

The dark side of this trend is that some individuals grasp the concept that the environment has an effect on people, and that there is evidence to support it—but go no farther. However well meaning, they can take isolated comments from an article or a conference presentation, make a personal interpretation that fits their design bias, and claim the subsequent design is evidence-based. These "Level Zero" practitioners have rarely read the original research, do not understand how to draw valid broad inferences from narrow and precise studies and, as a result, misapply important principles. Without hypothesis and measurement, these designers complete projects and search for any observable success. While these successes may be trumpeted as "evidence," the absence of a prospective statement of design intent breaks any link of planned causality. Such a design may have observed outcomes, but was never evidence-based. I'm tired of hearing any project with carpet, indirect lighting and popular colors touted as a "healing environment." Show us your results!

Evidence-based design is an important concept for healthcare clients to understand. Using it to design healthcare facilities can help improve the quality of healthcare for everyone, as well as lower costs in an industry that is struggling to contain them. It is even more important that design practitioners do not lead these clients astray by claiming to be something they're not.

  • D. Kirk Hamilton is a member of The Center for Health Design's board of directors. A founding principal with Watkins Hamilton Ross Architects in Houston,TX, he is leader of Q Group Advisors, the firm's consulting division. He is a past-president of the American College of Healthcare Architects and the AIA Academy of Architecture for Health and a member of the board of directors of the Coalition for Health Environments Research. He has authored and edited three books on health facility design and is currently working on a new book about evidence-based design for critical care. He recently completed a Master of Science in Organization Development at Pepperdine University. Hamilton can be reached at