Evidence-Based Design Shapes Healthcare Facilities

Research about what works and what doesn’t in healthcare facilities gives industry professionals a better picture of how to design for the future


The following article originally appeared in the January 2007 issue of Buildings magazine.

The healthcare industry is guided by painstaking research - studies and benchmarking guide treatment breakthroughs, pharmaceutical innovation, equipment design, and surgical techniques.

Without the evidence gleaned from ongoing research, healthcare would be mired in a sea of outdated medical procedures and drugs.

So, why should the facilities that house the most modern medical techniques and treatments remain trapped in the past? "Innovation in healthcare facilities has been slow and has not really been measured, proven, or disproven," notes Rosalyn Cama, chair of the Concord, CA-based Center for Health Design's board of directors and president at Cama Inc., a New Haven, CT, interior design firm.


A typical hospital construction project can take anywhere from 5 to 9 years from start to finish; once completed, it's expected to last at least 50 years. Evidence-based design allows new facilities to be flexible, adaptable, and future ready.

The U.S. healthcare system is anticipating a $200 billion hospital construction boom over the next decade. The challenge is keeping these facilities modern in the areas of technology, design, safety, security, and sustainability by the time they open. Evidence-based design - making decisions about the design of a healthcare facility based on the best information available from research and project evaluations - can do just that.

And, just as evidence-based medicine has revolutionized healthcare treatment, evidence-based design is transforming the healthcare environment by providing a record of proven architectural methods that will aid in improving patient outcomes, safety, and satisfaction, as well as boost staff retention and service efficiency now and into the future.

Longevity in Design
A typical hospital construction project can take anywhere from 5 to 9 years to move from the planning stages to the day when the first patient is admitted.

According to facilities experts at Kaiser Permanente's national facilities services department in Oakland, CA, hospital construction in California typically runs between 7 and 7.5 years from the initial stages to opening for patient treatments. "If you're taking 5 to 7 years to build a building that will last 50 years, it has to be flexible," says Wendy Weitzner, co-director of strategy, planning, and design for Kaiser Permanente's national facilities services department. "You can't possibly have a building that is going to be right 50 years from now, so you have to figure out how to accommodate a lot of changing."

Evidence-based design allows facilities professionals to use scientific research to plan, design, construct, and operate healthcare facilities that are geared toward promoting not only treatment, but more conducive healing and working environments. Such evidence will also allow facility design and construction to be flexible, adaptable, and future ready - even for a future that might not be imaginable when the project first hits the boards.

"These are all causing a shift in the way we design our medical facilities," Cama notes, indicating that forward-thinking healthcare design is more than just creating an attractive lobby or putting swags and jabots in a patient's room to make it more like home.

Pebble Project
In 2000, The Center for Health Design decided it was time to gather this important data. The Pebble Project, a joint research effort between the center and selected healthcare providers, does just that.

The study, which includes 36 active provider partners, three corporate partners, and two "alumni" partners, provides researched and documented examples of healthcare facilities where design has "made a difference in the quality of care and financial performance of the institution."

"[These partners] are measuring design outcomes so that we can have a database that examines the degree to which it works," says Cama. "More importantly, we're also asking them to build a business case for it. They need to be willing to spend the money to achieve a certain design feature and see in the end what it will do to reduce operational costs or improve the revenue for their hospital."

Provider participants ultimately hypothesize creative design innovations, build them, and then report in a peer-reviewed journal "for better or worse," Cama says. A comprehensive data summary of the project is available at (www.healthdesign.org/research/pebble/data.php).

Safety by Design
Because evidence-based healthcare design is still in its infancy, some healthcare providers have not yet fully embraced it as a standalone concept. They have instead incorporated its tenets into their own designs and plans for the future. Kaiser Permanente is one such provider.

"We're glad the field is headed in that direction," Weitzner notes. "But, we feel that the term 'evidence-based design' is a little overused right now. There are still so many variables in the built environment." The company's facilities decision- makers have incorporated the concept into their own holistic approach of creating future-ready facilities - an approach they call "safety by design."

"'Safety by design' is different than security," explains John Kouletsis, Kaiser's director of strategy, planning, and design. "It's a three-legged stool that encompasses three safety aspects: environment, patient, and workplace." Kouletsis says this approach relates back to evidence-based design, but on a more-detailed scale. "We're approaching our planning and design with a more rigorous attitude," he says.

Kaiser now does its internal benchmarking at the new Sidney R. Garfield Health Care Innovation Center. The 30,000-square-foot warehouse space has been set up as an inpatient unit mock-up, almost like a Hollywood set. It features a fully furnished and equipped medical prep room, a nurses' station, and patient rooms, as well as an operating room, an emergency treatment room, and a labor-and-delivery room. The space allows Kaiser Permanente professionals to run safety-by-design simulations. It's been open since June and focuses not only on product safety and design testing, but also on operational safety and design and testing for Kaiser Permanente's IT backbone.

Testing centers and initiatives like the Garfield Center and the Pebble Project have started to lay the groundwork for better understanding the direction that healthcare facilities need to take to tackle future demands, even though evidence is showing that meeting future needs might mean extra planning and higher additional first costs.

"It all ties back to the evidence," says Kouletsis. "Because we build, own, and operate our facilities, we are much more comprehensive on how we look at it. We look for a return of around 3 years. It has to be a total cost of ownership, not just a first cost."

Robin Suttell, based in Cleveland, is former contributing editor at Buildings magazine.


Lessons Learned

Evidence gathered in the aftermath of disasters such as 9/11 and Hurricanes Katrina and Rita has started to reshape the way healthcare facilities are designed and used, particularly in the area of disaster readiness.

"There wasn't a big emphasis on disaster preparedness until 9/11," says Don West, director of plant maintenance at Sentara Williamsburg Regional Medical Center, Williamsburg, VA. "And, with Katrina and the disasters happening down in New Orleans - hospitals with generators in basements that got flooded - people didn't think about that stuff until then."

Retrofitting an existing hospital for disaster readiness that was built before the all-too-real threats of global terrorism and increasingly pervasive and damaging natural disasters is virtually impossible. As Sentara learned, new hospital construction may be the best way to meet these challenges.

When Sentara Healthcare began designing its new medical center in Williamsburg, VA, the lessons of 9/11 took center stage. With Williamsburg strategically located near key naval bases, a CIA training facility, and the FBI headquarters in Langley, VA, not to mention the fact that it lies in the heart of a major tourist area, disaster readiness was not an option - it was a requirement.

The hospital, which opened in August, features single-button locks to prevent contaminated walk-in patients from entering the facility except through the decontamination unit; a separate air-handling system for the 10-bed, short-stay observation unit; access to two local power sources, three back-up generators, and two 12,000-gallon external fuel tanks; a warehouse that stores water, batteries, and food; dual water hook-ups; and a structure and windows that are built to withstand a Category 2 hurricane. It's also 117 feet above sea level to prevent flooding.

"Everything we need to operate for about 72 hours is there," West says. "You need to keep your hospital [sustained] for about 72 hours in a disaster, and we can with this plan. We've built up our supplies. We want the hospital to be the beacon of safety for people."