Evidence-Based Design: Why the Controversy?

by Patty Looker

Recent articles and blogs from leaders in healthcare architecture continue to keep alive the controversies around evidence-based design (EBD). A key observation is that EBD is still an incomplete discipline. Further, we are seeing some professionals promote their purported competency in EBD as a marketing tool (gasp!) and that research findings are being quoted as definitive when they remain untested.

All of these occurrences are absolutely predictable when a new area of interest with substantive promise emerges in professional practice. The need to improve healing environments remains undeniable. In the healthcare sector, we have a useful model for a fact-based discipline in evidence-based medicine. As a former healthcare consultant, I remember clearly a similar dynamic from the early days of that developing discipline. Clinicians warned of premature application of early clinical pathway findings as both overhasty and inevitably leading to “cookbook medicine”. Yet, a majority of clinicians supported the quest for efficacious interventions regarding chronic illness (accounting for nearly 80 percent of all healthcare spending and affecting 133 million Americans—45 percent of the population), one of our most problematic public health challenges. Identifying evidence-based clinical pathways uncovered useful treatment approaches which demonstrably improved health outcomes.

A leading proponent and facilitator of the developing discipline of EBD, The Center for Health Design (Healthcare Design, Vol. 8, No. 9, September 2008, p. 8) has pulled together a multiple definitions and proposes the following definition:

Evidence-based design is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.

Who can argue with that as a positive objective for the future of healthcare architecture and interior design? As long as rigor and discipline continue to be applied to methodologically correct research, empirically-based and peer-reviewed, EBD is a welcome tool in the creative arsenal of multi-disciplinary efforts to improve the human experience in healthcare environments.

I particularly appreciate the perspective of Jaynelle F. Stichler, Doctor of Nursing Science, RN, Fellow, American College of Healthcare Executives (FACHE), who with D. Kirk Hamilton, FAIA, Fellow, American College of  Healthcare Architects (FACHA), is co-editor of the new Health Environments Research & Design Journal (HERD). In the “Editor’s Column” of the Spring 2008 issue, she suggests that “evidence-based healthcare design is both art and science—a new and shared science, and the outcomes of designs based on evidence, common beliefs, or shared opinions will influence patient safety and outcomes and provider experiences for decades to come”. She sees the potential of evidence-based design as transformational, a multidisciplinary approach that starts with the question:

What is the effect of a specific design feature on a desired outcome such as improved patient outcome, safety, efficiency, satisfaction, retention, cost, or culture?

She also connects the future of evidence-based design to a systems perspective necessary for successful implementation, recognizing the inter-relatedness of elements in the complex, dynamic configuration that is healthcare delivery, architecture and human experience.

Debra Levin, President and CEO of The Center for Health Design (www.healthdesign.org) concurs; “though there is a copious amount of well-researched information already available, it is still nowhere all that we need to know to ensure that every significant decision we make has science behind it.” Current useful sources of information include the Robert Wood Johnson Foundation database, InformeDesign (www.informedesign.umn.edu) from the University of Minnesota, the U.S. Agency for Healthcare Research and Quality and the new Ripple database being developed by the Center for Health Design.

Therefore, all disciplines seeking to improve healthcare environments so they become a platform for improved health outcomes for individuals and those who love them, should step back and acknowledge the proverbial glass as half full rather than half empty. We should join with experts in all disciplines to advocate for application of evidence-based design practice, whether the research comes out of academic architectural programs, nursing schools, interior design firms, provider settings, product research or neuroscience. And beyond question, application of findings from the highest quality research must be translated into the business case for implementing EBD strategies. Our working premise in healthcare architecture is that healthcare providers have many good ways to spend their resources. We must help them balance proven facility improvement strategies with associated costs and benefits against other expenditure imperatives.

If the current healthcare system in America requires dramatic change, it follows that expertise that serves it must achieve new levels of innovation. The combination of science and art remains highly complex; therefore, advancements are particularly satisfying. Let’s not lament the incomplete regarding evidence-based design research; let’s cheer the potential of better built environment platforms supporting improved health outcomes.

Patty Looker, FACHE, is a principal and Healthcare Director at VOA Associates Incorporated, in Chicago. (www.voa.com).